Leadership skills training in Psychiatry: A European-based cross-sectional survey

Introduction

Leadership in healthcare organisations is crucial to continually improve and provide high quality compassionate care. Leadership development and training enables the psychiatrists in developing these essential skills. Focusing on how to enhance leadership development through leadership skills training and experiential learning should be a priority. However, little is known about the extent to which this leadership skills training is available across Europe in the early stage of the career of psychiatrists.

Objectives

To investigate the access to leadership development opportunities among European psychiatric trainees and early career psychiatrists (ECPs) and their perceptions related to leadership skills training.

Methods

Cross-sectional study, using an online survey consisting of multiple-choice questions and free text responses.

Results

Participants from 33 European countries took part in this survey, where the majority were female. More than half were general adult psychiatric trainees and more than a quarter ECPs. About half indicated having no access to leadership skills training within their training program, with only about 10% being satisfied with the training received. About half sought additional training outside their program. A vast majority requested training in leadership skills to be included in a psychiatric training program.

Conclusions

Our study provides an overview of important gaps in availability and access to leadership skills training amongst psychiatric trainees and ECPs across Europe. We hope that this study will help inform future actions pertaining to development and improvement of leadership skills training for trainees and ECPs across Europe.

Disclosure

No significant relationships.

Imbalance between pro- and anti-inflammatory cytokines, and between Th1 and Th2 cytokines in depressed patients: the effect of electroacupuncture or fluoxetine treatment

BACKGROUND

An increase in inflammatory response and an imbalance between T-helper (Th) 1 and 2 functions have been implicated in major depression. The aims of the present study were to 1) study the relationship between pro- and anti-inflammatory cytokines and between Th1 and Th2 produced cytokines in depressed patients and 2) evaluate and compare the effect of treatments with electroacupuncture (EA) and fluoxetine on these cytokines.

METHODS

95 outpatients with major depressive disorder were treated for 6 weeks with EA, fluoxetine or placebo. Hamilton Depression Rating Scale (HDRS) and Clinical Global Impression (CGI) were used to assess severity and therapeutic effects. 30 volunteers served as controls. Serum cytokine concentrations were measured by ELISA.

RESULTS

Increased proinflammatory cytokine interleukin (IL)-1beta and decreased anti-inflammatory cytokine IL-10 were found in the depressed patients. By contract, Th1 produced proinflammatory cytokines, tumor necrosis factor (TNF)-alpha and interferon (IFN)-gamma were decreased, and Th2 produced cytokine IL-4 was significantly increased in depressed patients. The ratio of IFN/IL-4 was also increased. Both acupuncture and fluoxetine treatments, but not the placebo, reduced IL-1beta concentrations in responders. However, only acupuncture attenuated TNF-alpha concentration and INF-gamma/IL-4 ratio towards the control level.

DISCUSSION

These results suggest that an imbalance between the pro- and anti-inflammatory cytokines (IL-1 and IL-10), and between Th1 and Th2 cytokines (INF-gamma or TNF-alpha and IL-4) occurred in untreated depressed patients. Both EA and fluoxetine had an anti-inflammatory effect by reducing IL-1beta. EA treatment also restored the balance between Th1 and Th2 systems by increasing TNF-alpha and decreasing IL-4.

Women's mental health in the Muslim world: cultural, religious, and social issues

In Arab communities, several cultural factors, derived mainly from the subordinate position of women, have been shown to affect the prevalence, clinical picture, health seeking behaviour, course and management of psychopathology in women. Women are definitely at a greater risk of developing mental disorders such as depressive, somatoform, anxious or eating disorders, as well as suicidal behaviors. Furthermore, mentally ill women are more stigmatized, have less access to care and suffer from a worse social outcome. This paper describes a series of culture-related risk factors such as education, work, sexuality, marriage, and infertility, which significantly contribute to triggering mental disorders in females, or to worsen their course and outcome. The authors recommend that mental health providers should play a critical role by addressing the cultural as well as psychological conditions that create and maintain threats to women's mental health.

What does Chilean research tell us about postpartum depression (PPD)?

BACKGROUND

In Chile, a country with a so called emerging market-economy, where rapid social and life style changes are taking place, women and the more socially disadvantaged are more at risk of becoming depressed.

METHODS

Results of several studies are summarized in the context of a review of the literature.

RESULTS

A third of Chilean women have depressive and/or anxiety symptoms during midpregnancy, while prevalence figures both in the early and the late postpartum period increase up to 50% in most studies. If strict operational criteria describing well defined depressive disorders are used postnatally, differences in prevalence and incidence figures arise depending on socioeconomic status. Whereas incidence rates for postpartum depression (around 9%) are very similar to those found in the northern hemisphere and do not appear to vary across different socioeconomic levels, higher prevalence rates are found among women from lower socioeconomic status.

LIMITATIONS

The studies focused on current diagnostic entities and did not consider different clusters or dimensions.

CONCLUSION

A shared biological etiology may be triggered by the physiology of childbirth and account for similarities in incidence across different socioeconomic levels. In turn, we hypothesize that the higher prevalence of postpartum depression (PPD) in Chilean women from lower socioeconomic status is the result of pre-existing depression and is not caused by more new cases of the illness.

Mental health of Moroccan women, a sexual perspective

Sexuality is a complex process coordinated with neurological, vascular, and endocrine systems. It incorporates family, societal, and religious beliefs and interpersonal relationships. Sexuality in the Muslim world is further complexed by tradition and discrimination of women. Studies conducted in Ibn Rushd University Psychiatric Center, Casablanca, Morocco, explored various aspects of sexuality in a traditional Muslim society: sexual behaviour (representative sample of Casablanca population n=728), sexual dysfunction (n=644), prevalence of abuse during childhood, effect of breast removal on sexuality (prospective study on 100 patients), effect of menopause on sexuality (comparative study between Moroccan and Tunisian samples, n=200), pregnancy and sexuality (follow up study in primary health care, n=100), and Ramadan and sexuality among healthy fasting people.

The diagnosis of premenstrual syndromes and premenstrual dysphoric disorder--clinical procedures and research perspectives

Premenstrual syndromes (PMS) are quite prevalent among women of reproductive age. In up to 20% of women they are severe enough to warrant treatment, which is available and marketed as such. The impact of the cumulative burden of PMS is substantial and is in the same magnitude as affective disorders. Nevertheless, the definitions and diagnoses of PMS are still fragmented, not widely accepted and, if accepted, not always applied in day-to-day clinical practice. In the present paper, the current diagnostic entities are critically reviewed, problems with the current definitions are delineated and a unified definition is proposed. For clinical purposes, the recommended dinical practical diagnostic process and differential diagnosis are described. For clinical trials of medications for treatment of PMS/premenstrual dysphoric disorder, research diagnostic criteria, inclusion and exclusion criteria, as well as well-defined outcome measures, are of utmost importance; they are described here. The gaps of knowledge in the description and diagnosis of PMS are described, with suggestions for future directions for research.

Effects of alcohol and other drugs in women of reproductive age: hormonal interactions

Neuroendocrine control of the menstrual cycle is very complex, and the pulsatile hormonal secretory patterns characteristic of the follicular, ovulatory and luteal phases can interact, under certain conditions, with alcohol and other drugs to modulate their effects. The presence of the premenstrual syndrome, with its characteristic symptoms of depression and anxiety, appears to be a critical factor in determining whether alcohol and drug use patterns increase during the premenstruum.

Hormonal aspects of schizophrenias: an overview

Although the lifetime risk and prevalence of schizophrenia are comparable for men and women, gender differences occur in various aspects of the disease, including age of onset, pathophysiology, symptoms, course, and response to treatment. These gender differences strongly suggest a key role played by gonadal hormones and their interactions with neurotransmitters. They may also suggest a key role for future applications of specific estrogens for improved treatment of schizophrenics.'Atypical' antipsychotics definitely improved the benefit/risk ratio of treatment of schizophrenic patients. However, they shift the reasons for noncompliance from extrapyramidal symptoms to hormonally related adverse effects, mostly weight gain and impaired sexual functions (which occur in men and women, but cause noncompliance mostly in men). Diabetes, dyslipidemia, and decreased bone mineral density, as well as some other adverse effects are more 'silent' but their long-term effects are detrimental. 'Hormone-friendlier' interventions might be needed.

Elevated prolactin levels in patients with schizophrenia: mechanisms and related adverse effects

The neurologic processes involved in schizophrenia are complex and diverse and the mechanisms through which antipsychotic agents exert their effects have been only partly elucidated. Hyperprolactinemia is a common side effect of treatment with many antipsychotics and is particularly associated with conventional ('typical') agents as well as the atypical antipsychotic risperidone. In contrast, other atypical agents introduced over the last decade do not elevate prolactin levels. This article discusses the regulatory mechanisms involved in prolactin secretion, the physiologic role of prolactin, and the etiology of hyperprolactinemia. Elevated prolactin levels may play important roles, both direct and indirect, in various pathologic states, including breast cancer, osteoporosis, cardiovascular disorders, and sexual disturbances. Antipsychotic-induced hyperprolactinemia may be associated with similar clinical manifestations; these are examined with particular reference to patients with schizophrenia.

The second-generation 'atypical' antipsychotics: similar improved efficacy but different neuroendocrine side effects

The neuroendocrine aspects of schizophrenia generally receive little attention. This is in marked contrast to depressive disorders, where neuroendocrine issues are central to discussions of pathophysiology and treatment. Although the nature of neuroendocrine dysfunction is less well characterized in schizophrenia than in major depression, a number of neuroendocrine abnormalities have been described. Hypercortisolemia has been extensively documented in patients with schizophrenia, particularly during acute exacerbations, with persistent hypercortisolemia being associated with ventricular enlargement and poor outcome. Similarly, abnormalities in thyroid function, the hypothalamo-pituitary-gonadal axis, growth hormone, prolactin, neurotensin, and other neuroendocrine parameters have also been described in schizophrenia. While the precise neuroendocrine profile of schizophrenia is incompletely characterized, the impact of antipsychotic medications employed in its treatment on various endocrine parameters is better understood. Different conventional and atypical antipsychotics variably contribute to hyperprolactinemia, insulin resistance, and other abnormalities. A critical overview of neuroendocrine abnormalities in schizophrenia is provided and the differential impact of different antipsychotics in contributing to neuroendocrine dysfunction is discussed.

Role of estrogen in the aetiology and treatment of mood disorders

Worldwide, the prevalence of depression in women is significantly greater than in men. Available data suggest that estrogen, or its absence, is strongly implicated in the regulation of mood and behaviour, as well as in the pathobiology of mood disorders. The multiple effects of estrogens and their complex interactions with the CNS and endocrine system have been well documented, although the specific, multifaceted role of estrogen in each dysphoric state has yet to be elucidated. Several facts suggest that estrogen plays a vital role in the precipitation and course of mood disorders in women. Gender differences in the prevalence of depression first appear after menarche, continue through reproductive age, and dissipate after perimenopause. Periods of hormonal fluctuations or estrogen instability (i.e. premenstrually, postpartum, perimenopausally) have been associated with increased vulnerability to depression among susceptible women. It is plausible that the phenotype of these depressions is distinguishable from those that are not associated with reproductive events or that occur in men. Based on current knowledge, estrogen treatment for affective disorders may be efficacious in two situations: (i) to stabilise and restore disrupted homeostasis - as occurs in premenstrual, postpartum or perimenopausal conditions; and (ii) to act as a psychomodulator during periods of decreased estrogen levels and increased vulnerability to dysphoric mood, as occurs in postmenopausal women. There is growing evidence suggesting that estrogen may be efficacious as a sole antidepressant for depressed perimenopausal women. It is still unclear whether estrogen is efficacious as an adjunct to selective serotonin reuptake inhibitors or as one of the paradigms to manage treatment-resistance depression in menopausal women, but such efficacy is plausible.

Oral contraceptives and mood

The past 40 years of research on the mood and behavioural effects of combined oral contraceptives (OCs) have yielded inconclusive results due to dramatic changes in the compounds and to methodological flaws inherent in studies undertaken to assess the effects of OCs. Since the late 1960s, the dosages of oestrogen and progestin in marketed OCs significantly declined and novel progestins were developed to deliver higher levels of progestogenic activity with a lower risk of adverse oestrogenic and androgenic effects. This review evaluates controlled, comparative studies that have focused on the efficaciousness of OCs as treatment for premenstrual syndrome (PMS) and those examining whether OCs may cause negative mood. It is suggested that the mood and behavioural effects of OCs might be attributed to different progestin compounds and possibly, their oestrogen ratios. There is a great need for more longitudinal, randomised, placebo-controlled studies to further clarify the mood and behavioural effects of OCs.

Are women with premenstrual dysphoric disorder prone to osteoporosis?

OBJECTIVE

The objective of this study was to examine whether bone mineral density (BMD) is reduced in women with premenstrual dysphoric disorder (PMDD).

METHODS

Thirty-eight healthy women participated: 20 with prospectively confirmed PMDD and 18 without PMDD. Bone mass was measured using dual-energy x-ray absorptiometry at three sites: lumbar spine anteroposterior, lumber spine lateral, and femoral neck. Results from the PMDD and control groups were compared with each other and with age- and sex-matched normative data.

RESULTS

The BMD of both groups was as expected for their age and sex, and groups did not differ in BMD or Z scores for any of the bone sites studied.

CONCLUSIONS

If women with PMDD are at an increased risk of developing osteoporosis, this risk is not manifested in their BMD.

Effectiveness of St John's wort in major depression: a randomized controlled trial

CONTEXT

Extracts of St John's wort are widely used to treat depression. Although more than 2 dozen clinical trials have been conducted with St John's wort, most have significant flaws in design and do not enable meaningful interpretation.

OBJECTIVE

To compare the efficacy and safety of a standardized extract of St John's wort with placebo in outpatients with major depression.

DESIGN AND SETTING

Randomized, double-blind, placebo-controlled clinical trial conducted between November 1998 and January 2000 in 11 academic medical centers in the United States.

PARTICIPANTS

Two hundred adult outpatients (mean age, 42.4 years; 67.0% female; 85.9% white) diagnosed as having major depression and having a baseline Hamilton Rating Scale for Depression (HAM-D) score of at least 20.

INTERVENTION

Participants completed a 1-week, single-blind run-in of placebo, then were randomly assigned to receive either St John's wort extract (n = 98; 900 mg/d for 4 weeks, increased to 1200 mg/d in the absence of an adequate response thereafter) or placebo (n = 102) for 8 weeks.

MAIN OUTCOME MEASURES

The primary outcome measure was rate of change on the HAM-D over the treatment period. Secondary measures included the Beck Depression Inventory (BDI), Hamilton Rating Scale for Anxiety (HAM-A), the Global Assessment of Function (GAF) scale, and the Clinical Global Impression-Severity and -Improvement scales (CGI-S and CGI-I).

RESULTS

The random coefficient analyses for the HAM-D, HAM-A, CGI-S, and CGI-I all showed significant effects for time but not for treatment or time-by-treatment interaction (for HAM-D scores, P<.001, P =.16, and P =.58, respectively). Analysis of covariance showed nonsignificant effects for BDI and GAF scores. The proportion of participants achieving an a priori definition of response did not differ between groups. The number reaching remission of illness was significantly higher with St John's wort than with placebo (P =.02), but the rates were very low in the full intention-to-treat analysis (14/98 [14.3%] vs 5/102 [4.9%], respectively). St John's wort was safe and well tolerated. Headache was the only adverse event that occurred with greater frequency with St John's wort than placebo (39/95 [41%] vs 25/100 [25%], respectively).

CONCLUSION

In this study, St John's wort was not effective for treatment of major depression.

Selective oestrogen receptor modulators--current and future brain and behaviour applications

Selective oestrogen receptor modulators (SERMs) are compounds that act as oestrogen agonists on selected targets while being oestrogen antagonists on others. The main targets of SERMs are oestrogen agonist activity on bone metabolism and several functions of the cardiovascular system, as well as oestrogen antagonism in the breast and uterus. They are indicated for the treatment and/or prevention of breast and endometrial cancer, osteoporosis and coronary heart disease. The extensive documentation of the multiple oestrogen effects on the CNS, greater understanding of the mechanisms of action, and especially the discovery of a second oestrogen receptor with differentiated distribution and mechanisms, have all led the way to the possibility of specific CNS-targeted SERMs. The demonstration that oestrogen selectively improves cognition, delays the appearance of Alzheimer's dementia, improves the feeling of well-being, as well as the response to antidepressant medications, provides targeted CNS indications for SERMs. The CNS effects of the currently marketed SERMs are not sufficiently explored yet. However, in postmenopausal women, tamoxifen and raloxifene probably show the most oestrogen agonist CNS effects. In women of reproductive age, competition with oestrogen probably exists, resulting in antagonist effects. Activity in men is still mostly unknown. It is quite safe to predict that the recent accumulation of knowledge, combined with the large, thirsty anticipated market for these 'designer oestrogens', will lead to clinical trials of CNS-targeted SERMs in the very near future.

Imidazoline and alpha(2a)-adrenoceptor binding sites in postmenopausal women before and after estrogen replacement therapy

BACKGROUND

Platelet alpha(2A)-adrenoceptors (alpha(2A)AR) and imidazoline binding sites (subtype I(1)) have been proposed as peripheral markers of brain stem receptors that mediate sympathetic outflow and are reported to be elevated in major depression.

METHODS

In our study, p[(125)I]-iodoclonidine was used to assess platelet alpha(2A)AR and I(1) binding sites in healthy postmenopausal women (n = 34) compared with healthy women of reproductive age (n = 26). Receptor determinations were repeated in 19 postmenopausal women following 59-60 days of estrogen replacement therapy (ERT; 0.1 mg estradiol transdermal patches).

RESULTS

I(1) binding sites were twofold higher in platelets of postmenopausal women compared with women of reproduction age but were down-regulated (normalized) after 59-60 days of ERT. All other binding parameters, including platelet alpha(2A)AR density, were not different between groups nor were they changed after ERT. Platelet I(1) densities after 59-60 days of ERT were positively correlated with plasma luteinizing hormone concentrations.

CONCLUSIONS

It is suggested that increased imidazoline binding sites might be associated with mood and behavioral changes in postmenopausal women.

Psychosocial functioning in women with premenstrual dysphoric disorder before and after treatment with sertraline or placebo

BACKGROUND

The objective of this study was to evaluate the pretreatment psychosocial functioning of women with premenstrual dysphoric disorder (PMDD) and the effect of sertraline treatment on psychosocial functioning in these patients.

METHOD

Two hundred forty-three women recruited from 12 university-affiliated sites and meeting DSM-IV criteria for PMDD completed 1 cycle of single-blind placebo and were randomly assigned to flexible dose sertraline or placebo for 3 cycles. Psychosocial functioning was assessed by the Daily Record of Severity of Problems (DRSP), the Social Adjustment Scale (SAS), and the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q).

RESULTS

SAS scores during the follicular phase were similar to SAS scores of community norms, whereas the pretreatment SAS and Q-LES-Q scores during the luteal phase were similar to scores of women with depressive disorders. Sertraline was significantly more effective than placebo in improving psychosocial functioning as measured by the SAS, the Q-LES-Q, and the 3 DRSP items of impaired productivity, interference with social activities, and interference with relationships with others. Improvement in psychosocial functioning assessed by SAS and Q-LES-Q correlated with improvement in symptomatology assessed by the Clinical Global Impressions-Improvement (CGI-I) scale and the Hamilton Rating Scale for Depression (HAM-D). Remitters (CGI-I score of 1) were more likely to function better at baseline and showed larger improvements in functioning and quality of life with treatment compared with nonremitters.

CONCLUSION

Sertraline was superior to placebo in improving psychosocial functioning in women with PMDD as reflected by SAS, Q-LES-Q, and DRSP measures. Functional improvement correlated with improvement in premenstrual symptomatology and was apparent by the second cycle of treatment. Comparison of pretreatment SAS scores in women with PMDD with the scores of other populations of women documents the degree of luteal phase functional impairment in women with PMDD and a relative absence of follicular phase impairment.

Premenstrual syndromes: closing the 20th century chapters

The need to re-evaluate premenstrual syndromes became apparent in 1997-1998 and early 1999. The success stories of some symptomatic treatment modalities and more sophisticated studies of pathobiology chart the pathways for future progress: the shift from a descriptive diagnosis to diagnoses based on etiology, the recognition of diversified vulnerabilities and their expression in particular situations, and specific treatment modalities.

Premenstrual syndromes

Premenstrual syndromes (PMS) are a group of menstrually related, chronic, cyclical disorders manifested by emotional and physical symptoms in the second half of the menstrual cycle. A diagnosis of PMS is based on the timing and symptom pattern observed in daily symptom reports maintained by the patient. The etiology is unknown but is believed to involve genetic and dynamically evolving vulnerability, reproductive hormones, and neurotransmitters, as well as other brain processes. Effective medications have been identified for acute hormonal and symptomatic treatment of the disorder, but the time course and frequency of relapse and recurrence remain poorly understood. Further studies of PMS in all areas--etiology, pathobiology, diagnosis, course of illness, and treatment efficacy--are needed to increase the body of information about the menstrual cycle's effects on women's health and mood disorders.

Evaluation of women's mental health: delineation of the field, and needs and steps toward a consensus

Mental health studies that investigate the behavior, mood, perception, cognition, and biology associated with specific conditions of women or with situations characterized by substantial gender differences are proliferating in number and progressing in quality, depth, and scope. To solidify the field, there is a need for a consensus on definitions and diagnostic criteria, standardized clinical assessment procedures, and large-scale interdisciplinary collaborative efforts to effectively study and illuminate the diversified aspects of women's mental health. Under a professional services contract with the National Institute of Mental Health, researchers who investigate women's mental health met during the American Psychiatric Association (APA) meeting in San Diego, California, on May 19, 1997. The 18 participants discussed key clinical and biological assessments and subsequently submitted papers reflecting scientific conclusions and recommendations for standardizing these assessments. It was agreed that a unified assessment instrument would be beneficial, but due to the widespread requirements and numerous factors that are critical in assessing all areas of women's health, situation-specific forms are often needed. The background, rationale, and process of the meeting are described here, whereas the details and recommendations are described in individual position papers.

Future directions for studies of women's mental health

Women's mental health is increasingly recognized as a major field with an impact on the well-being of individuals, their families, and society. It is also recognized that this field is in its infancy and needs to be well delineated: Definitions and assessment procedures for the various topics need to be developed; the pathobiologies are as yet unknown; and time course, variations, and treatment outcome of most of the entities included are unknown or not confirmed. Also, interactions among phenomena, biology, environment, and sociopsychological aspects have not been well studied. A group of investigators whose focus is on various aspects of women's mental health, especially reproduction-related dysphorias, met and discussed their respective priorities for studies in the field. Mechanisms and operational vehicles to effectively achieve the expressed goals and to conduct the proposed studies are presented.

Effects of electroconvulsive therapy on plasma vasopressin and oxytocin

BACKGROUND

Animal studies suggest that vasopressin has cognitive-enhancing properties and oxytocin may have amnestic effects. A clinical report suggests that the acute increase in oxytocin-associated neurophysin predicts clinical response to electroconvulsive therapy (ECT) in depressed patients.

METHODS

Medication-free patients with major depression were randomized to receive right unilateral or bilateral ECT administered with electrical stimulus intensity at either just above seizure threshold or at 150% above seizure threshold. The associations between plasma vasopressin, oxytocin, ECT treatment parameters, clinical outcome, and cognitive effects were assessed.

RESULTS

The sample comprised 55 patients. At the second ECT, patients receiving ECT at 150% above initial seizure threshold had significantly greater increases in plasma vasopressin than patients receiving low-dose ECT (ps < .01-.04), with no effects of electrode placement. At the second and ninth ECT treatments, the vasopressin or oxytocin surges were not associated with clinical improvement, seizure duration, time to orientation, or memory test performance. There were inverse trend-level associations between the acute surge in oxytocin levels at the ninth ECT and clinical response, contradicting a report in the literature.

CONCLUSIONS

Overall, these findings do not support the hypothesis that diencephalic seizure propagation is central to the mechanism of action of ECT.

State and trait serotonergic abnormalities in women with dysphoric premenstrual syndromes

Three to eight percent of women of reproductive age suffer from dysphoric premenstrual disorder (PMS). Although the exact pathophysiology of this disorder is not known, serotonergic dysregulation appears to be involved. In this article, we review and summarize the current data on changes in serotonergic parameters in women with dysphoric PMS and emphasize the distinction between state-related abnormalities which are present only during the symptomatic late-luteal phase and trait abnormalities which are present even during non-symptomatic phases of the menstrual cycle. The notion of diversified serotonergic systems that are selectively affected by fluctuations in gonadal hormones is discussed in the context of PMS as well as other dysphorias.

Psychotropic effects of hormonal replacement therapy

Estrogens have been shown to have a positive effect on mood and cognition. The effect on mood is probably by modulation of other processes, but estrogen probably is not an effective antidepressant when given alone. The effect on cognitive function is mostly favorable and direct, but might vary according to the specific task involved. Some progestins counteract the effects of estrogen and especially when administered in a sequential dosing might cause dysphoria. The mood effects of mixed estrogen-like compounds are not yet established. It may be predicted that eventually the cognitive effects of estrogen replacement therapy for postmenopausal women will be recognized as an additional indication for that hormone.

Hormonal treatments for premenstrual syndrome

Ovarian function appears to play a fundamental role in premenstrual syndrome (PMS). Accordingly, treatment strategies designed to suppress ovulation have generally been found to be effective for treatment of menstrually related syndromes and symptoms. GnRH agonists and Danazol(R) are probably inferior to estrogen, due to their unfavorable side effects profile. In addition, it is worthwhile to emphasize that in spite of the publicity of progesterone treatment for PMS, in most well-controlled studies it has not been shown to be more effective than placebo for the treatment of these syndromes. The efficacy of hormonal treatments that do not suppress ovulation is still controversial.

Menstrually related disorders--towards interdisciplinary international diagnostic criteria

Premenstrual and catamenial disorders are prevalent, diversified and involve various body systems. The mechanisms and management of the menstrually related disorders (MRDs) are hampered by a fragmented approach because each cluster of symptoms is studied and treated by specialists in a number of related disciplines. The apparent common denominator of MRDs, an association with the menstrual cycle, also carries with it associations with ovulation and ovulation-related hormonal and cyclic biological changes. To achieve progress in understanding and treating MRD, an interdisciplinary nomenclature and diagnostic system are needed. Criteria based on temporal occurrences and not on phenomenology have been developed after interdisciplinary discussions and are herein proposed.

Symptomatic improvement of premenstrual dysphoric disorder with sertraline treatment. A randomized controlled trial. Sertraline Premenstrual Dysphoric Collaborative Study Group

CONTEXT

Premenstrual dysphoric disorder is an important cause of symptoms and functional impairment in menstruating women.

OBJECTIVE

To evaluate the efficacy of sertraline hydrochloride for treatment of premenstrual dysphoria by measuring changes in symptom expression and functional impairment.

DESIGN

Two screening cycles followed by 1 single-blind placebo cycle and 3 cycles of randomized, double-blind, placebo treatment.

SETTING

Twelve university-affiliated outpatient psychiatry and gynecology clinics.

PATIENTS

Of the 447 women who requested participation, 243 met criteria for premenstrual dysphoric disorder and were randomized; 200 women completed the study.

INTERVENTION

A flexible (50-150 mg) daily dose of sertraline hydrochloride.

MAIN OUTCOME MEASURES

The Daily Record of Severity of Problems, Hamilton Rating Scale for Depression, Clinical Global Impression Scale, and Social Adjustment Scale.

RESULTS

Mean (+/-SD) total daily symptom scores decreased significantly (P<.001) in the sertraline-treated (64+/-22 to 44+/-19) compared with the placebo-treated (62+/-22 to 54+/-24) groups. Significant improvement (P<.05) was found for all clinically derived symptom clusters (depressive, physical, and anger/irritability symptoms). Hamilton Rating Scale for Depression scores decreased by 44% and 29% in the sertraline and placebo groups, respectively (P<.002). End-point global ratings showed much or very much improvement in 62% of the active treatment group and 34% of the placebo treatment group (P<.001). Reported functional impairment was substantial at baseline. Improvement in psychosocial functioning with treatment was similar to what is found in studies of major depression.

CONCLUSIONS

Sertraline was significantly better than placebo for treatment of premenstrual dysphoria as reflected by symptomatic improvement and change in reported functional impairment. Serotonin reuptake inhibitors such as sertraline are useful therapeutic options for women with premenstrual dysphoria.

Intermittent luteal phase sertraline treatment of dysphoric premenstrual syndrome

BACKGROUND

Dysphoric premenstrual syndrome (PMS) has been associated with serotonergic dysregulation, and serotonergic medications have been reported to alleviate the symptoms of PMS. We investigated the effects of the serotonin reuptake inhibitor sertraline given during only the luteal phase in women with dysphoric PMS.

METHOD

After baseline ratings were obtained during two menstrual cycles, 15 women with dysphoric PMS who also met DSM-IV criteria for premenstrual dysphoric disorder (PMDD) entered single-blind treatment with sertraline 100 mg/day for one full menstrual cycle. Women who responded to this treatment were randomly assigned to a four-cycle double-blind placebo-controlled crossover study in which sertraline 100 mg/day or placebo was each given only during luteal phases of two consecutive menstrual cycles.

RESULTS

Eleven (79%) of fourteen women responded to single-blind full-cycle treatment with sertraline and were randomly assigned to the double-blind crossover study. Three patients dropped out of the study while taking placebo owing to nonresponse. For the remaining patients, sertraline given during the luteal phase produced significant improvements in depression, impairment, and global ratings compared with placebo and was equivalent in efficacy to sertraline given during the entire menstrual cycle.

CONCLUSION

Women with dysphoric PMS who responded to continuous sertraline treatment responded equally well to sertraline treatment that was restricted to the luteal phase. Luteal phase treatment may have advantages in side effect burden and costs. Larger controlled trials are warranted to confirm this finding.

Role of estrogen in postmenopausal depression

Estrogen has been reported to improve the cognitive functioning of postmenopausal women. It is suggested that estrogen replacement therapy (ERT) might be beneficial for improvement of mood and cognition in menopausal women. We have shown that this improvement is selective and is probably more apparent in complex integrative functions. We have also shown that estrogen can augment serotonergic activity as well as some norepinephrine-related processes in postmenopausal women. Because of its effects on mood-related neurotransmitter processes, ERT might decrease vulnerability to depression and be effective as an adjunct therapy to prevent treatment nonresponse to conventional antidepressants.

Premenstrual dysphoric disorders: a diversified cluster of vulnerability traits to depression

Some biological factors which have been shown to be abnormal in subgroups of women with dysphoric premenstrual syndromes (PMS) have not been limited to the symptomatic late luteal phase of the menstrual cycle, but also existed during the non-symptomatic mid-follicular phase of the cycle. Personality, cognitive functions, alpha 2 and imidazoline binding, sensitivity to inducement of panic attacks, relative hypothyroidism, and some but not all serotonergic functions of women with dysphoric PMS differ from those with no PMS, and also differ during a non-symptomatic phase of the cycle. It is suggested that premenstrual symptoms are an expression of vulnerability traits that might surface in response to a trigger. Such traits are probably diverse, and the nature of the symptoms might depend upon the underlying trait. It is postulated-that some vulnerability traits to specific premenstrual syndromes might also be vulnerability traits to depression or anxiety in general.

Double-blind comparison of sertraline, imipramine, and placebo in the treatment of dysthymia: psychosocial outcomes

OBJECTIVE

The purpose of this study was to determine the effects of antidepressant pharmacotherapy on mood symptoms and psychosocial outcomes in dysthymia.

METHOD

In a multicenter, double-blind, parallel-group trial, 416 patients with a diagnosis of early-onset primary dysthymia (DSM-III-R) of at least 5 years' duration without concurrent major depression were randomly assigned to 12 weeks of acute-phase therapy with sertraline, imipramine, or placebo. The psychosocial outcome measures used in the study were the Global Assessment of Functioning Scale, the Social Adjustment Scale, the Longitudinal Interval Follow-up Evaluation psychosocial ratings, and the Quality of Life Enjoyment and Satisfaction Questionnaire.

RESULTS

Sertraline and imipramine were significantly better than placebo in improving psychosocial outcomes as measured by the first three instruments. The Quality of Life Enjoyment and Satisfaction Questionnaire scores demonstrated significant improvements from baseline, and both active treatments produced significantly greater improvements than placebo. Significantly fewer patients discontinued sertraline (6.0%) than discontinued imipramine (18.4%) because of adverse events.

CONCLUSIONS

Pharmacotherapy is an effective treatment for dysthymia in terms of psychosocial functioning as well as depressive symptoms, even when the dysthymia is long-standing.

The undertreatment of dysthymia

BACKGROUND

Dysthymia is a chronic depressive condition that is quite prevalent. This condition can exact a significant toll on the general health and quality of life in the affected individual. Despite the frequency and consequences of dysthymia, however, the condition is often not diagnosed or treated. We present data on prior treatment from 410 patients with DSM-III-R dysthymia, primary type, early onset without concurrent major depression.

METHOD

Axis I and II diagnoses were made by using the Structured Clinical Interviews for DSM-III-R, Patient Version (SCID-P) and SCID II for Personality Disorders. The Hamilton Rating Scale for Depression and the Clinical Global Impressions scale were also completed. Prior treatment was assessed, with special attention paid to previous antidepressant drug therapy and psychotherapy.

RESULTS

Although the mean duration of dysthymia was about 30 years and almost half of the patients had previous episodes of major depression, only 41.3% had been treated with antidepressants and 56.1% with psychotherapy. A past history of major depression increased the frequency of prior antidepressant pharmacotherapy (45.7%) and psychotherapy (59.4%) compared with no history of major depression (36.8% and 40.9%, respectively). Comorbid personality disorder increased the likelihood of prior psychotherapy (70.7% vs. 49.6%) while having no effect on past pharmacotherapy. A history of substance abuse did not affect the history of antidepressant or psychotherapy treatment. In this study, dysthymia and psychosocial outcomes improved with sertraline and imipramine treatment.

CONCLUSION

Dysthymic patients in this sample were significantly undertreated. Newer antidepressant agents may alter the potential for pharmacotherapy interventions in this vulnerable population.

Hormonal interventions with psychopharmacological potential: an overview

The better understanding of how hormones modulate cognition and behavior is associated with the application of hormones as psychotropic medications. Several natural and synthetic hormones are used as adjuncts to antidepressant medications or as treatments in their own right. We discuss pharmacotherapeutical aspects of estrogen, thyroid hormones, cortisol suppressors, and melatonin as examples of current trends in the field. In addition to the putative roles of these hormones in the treatment of affective disorders, estrogen might also be used as a cognition-enhancer, and both estrogen and thyroid hormones might have roles as mood stabilizers. The psychotropic effects of melatonin have recently received significant attention, but the exact role of that hormone still needs to be clarified.

The influence of estrogen on monoamine oxidase activity

The enzyme monoamine oxidase (MAO) has generated considerable interest as a biological marker. The serendipitous discovery that iproniazid was a weak MAO inhibitor (MAOI) led to the development and widespread use of MAOIs as antidepressants in the early 1950s. The-discovery of the two isoenzymes of MAO has led to the development of selective MAOIs that may have a more favorable side-effect profile. The regulation of MAO is multifactorial, and there is evidence that it involves estrogens. Improvement in mood and cognition reported in women on estrogen replacement therapy may also involve changes in MAO activity. The literature in this regard is reviewed here, and possible implications of the effects of estrogens on MAO activity are discussed.

A placebo-controlled, randomized clinical trial comparing sertraline and imipramine for the treatment of dysthymia

BACKGROUND

Despite the high prevalence of dysthymia and its associated morbidity, few controlled trials have evaluated the efficacy of antidepressant medication for this disorder. A 12-week, double-blind, placebo-controlled, randomized, multicenter trial was performed to evaluate the safety and efficacy of sertraline hydrochloride and imipramine hydrochloride in treating dysthymia.

METHODS

A total of 416 outpatients (271 women and 145 men) aged 25 to 65 years with DSM-III-R-defined, early-onset, primary dysthymia without concurrent major depression were randomized to 12 weeks of treatment with sertraline, imipramine, or placebo.

RESULTS

Both active treatments resulted in significantly reduced scores on the 17-item Hamilton Rating Scale for Depression (P = .04 and P = .01 for sertraline and imipramine vs placebo, respectively), the Montgomery-Asberg Depression Rating Scale (P = .01 and P = .003 vs placebo, respectively), Hopkins Symptom Checklist (P < .05), and the self-rated version of the Inventory of Depressive Symptoms (P < .05). With the use of a Clinical Global impressions improvement score of 1 or 2 (very much or much improved) to define response, response rates were 59% for sertraline, 64% for imipramine, and 44% for placebo (P = .02 for sertraline vs placebo and P < .001 for imipramine vs placebo). A significantly greater proportion of patients receiving imipramine than those receiving sertraline or placebo discontinued treatment because of adverse events (P = .001 and P < .001, respectively).

CONCLUSIONS

Pharmacotherapy provides considerable relief from the symptoms of dysthymia in patients suffering from this chronic affective disorder, with both sertraline and imipramine being more effective than placebo. The greater tolerability of sertraline is an important consideration because of the chronicity of dysthymia, which may require prolonged treatment with antidepressant medication.

Low plasma gamma-aminobutyric acid levels during the late luteal phase of women with premenstrual dysphoric disorder

OBJECTIVE

Plasma gamma-aminobutyric acid (GABA) levels have been reported to be low in some patients with major depressive disorder. Premenstrual dysphoric disorder is often associated with major depressive disorder. Therefore, the authors sought to determine whether women with premenstrual dysphoric disorder with or without prior major depressive disorder also had low plasma GABA levels.

METHOD

Plasma GABA levels were measured in 27 women with premenstrual dysphoric disorder and 21 comparison women during the the mid-follicular and late luteal phases of the menstrual cycle.

RESULTS

In comparison women, plasma GABA levels increased from the mid-follicular to the late luteal phase. Women with premenstrual dysphoric disorder and a past history of major depressive disorder had low plasma GABA levels during both phases. In women with premenstrual dysphoric disorder but no past major depressive disorder, plasma GABA levels decreased from the nonsymptomatic, mid-follicular phase to the symptomatic, late luteal phase.

CONCLUSIONS

Decreased GABA function may represent a common biological link between subtypes of depressive and premenstrual dysphoric disorders. A trait in major depressive disorder and a state-dependent decrease in premenstrual dysphoric disorder might imply a possible continuum between the two disorders.

Are chronic psychiatric patients at increased risk for developing breast cancer?

OBJECTIVE

The authors' goal was to assess the incidence of breast cancer among chronic psychiatric patients.

METHOD

They reviewed mammograms and charts of 275 female patients over the age of 40 in a state psychiatric hospital and 928 women of comparable age at a general hospital radiology clinic.

RESULTS

The incidence of breast cancer documented by pathology reports among the psychiatric patients was more than 3.5 times higher than that of patients at the general hospital and 9.5 times higher than the reported incidence in the general population.

CONCLUSIONS

If confirmed, the suspected higher incidence of breast cancer among the psychiatric patients might be due to medications and further underscores the need for screening mammograms for breast cancer in these patients.

Accelerated osteoporosis in psychiatric patients: possible pathophysiological processes

Osteoporosis, a very prevalent, potentially debilitating disease, is characterized by decreased bone mineral density (BMD). Decreased BMD has recently been reported in patients suffering from several mental disorders, including schizophrenia and major depression. In these patients the accelerated decrease in BMD can be attributed to drug-induced decreases in levels of estrogen and testosterone, to polydipsia and decreased calcium to smoking and alcoholism, and to increased activity of several interleukins as well as to hyperprolactinemia and hypercortisolemia. Several of these processes may be prevented or altered in order to prevent or delay decreased BMD.

Decreased bone mineral density in medicated psychiatric patients

Osteoporosis is a common problem in postmenopausal women. It has been linked to estrogen deficiency, other neuroendocrine processes such as hypercortisolemia and male hypogonadism, nutritional deficiencies, and other mechanisms. Some of these changes have been also reported in male and female patients with mental disorders, especially those receiving psychotropic medications. Therefore, bone mineral density was measured by dual-photon absorptiometry in the lumbar spine and in the femoral neck of 33 female and 35 male consenting psychiatric inpatients admitted consecutively. Patients were diagnosed as having major depressive disorder (N = 21), schizophrenia (N = 33), schizoaffective disorder (N = 7), mania (N = 2), and adjustment disorder (N = 5). Plasma levels of prolactin, estrogen, cortisol, and testosterone were also measured in a subgroup of these patients. It is reported that female patients, but especially male patients, had a highly significant decrease in bone mineral density when compared with age- and sex-matched normal data. It is suggested that psychiatric patients treated with antidepressants or neuroleptics might have decreased bone mineral density than is normal for their age and sex, and may be at an increased risk for fractures. These results may be related to low levels of gonadal hormones, especially in male subjects. Data should be confirmed with a larger number of patients with and without medications to distinguish between diagnosis-related and treatment-related effects.

Possible acceleration of age effects on cognition following menopause

Many cognitive functions have been shown to deteriorate with age. Because of the importance of the menopause as a milestone in the life cycles of women, we examined whether the aging-over-time process in some cognitive functions differs between women of reproductive age and postmenopausal women. It is demonstrated here that in some cognitive tests, including driving simulation, reaction time and some visuospatial tests, there is a significant acceleration in deterioration of functioning following menopause. It is suggested that this acceleration might be associated with the lack of gonadal hormones or other reproduction-related factors which may play a protective role against age-related deterioration in some cognitive functions in women.

Estrogen augments serotonergic activity in postmenopausal women

To investigate the influence of estrogen replacement on serotonergic activity in postmenopausal women, the serotonin agonist meta-chlorophenylpiperazine (m-CPP) (0.5 mg/kg) was given orally to 18 normal postmenopausal women, 11 of whom were also tested following 30 days' treatment with estrogen transdermal patches (estraderm 0.1 mg). Fifteen normal, healthy women of reproductive status served as a control group. Cortisol and prolactin responses to m-CPP were measured. Without estrogen, the prolactin and cortisol responses of postmenopausal women to m-CPP were blunted compared to those of reproductive women. Estrogen replacement increased the hormonal responses. It is suggested that decreased serotonergic activity in postmenopausal women might contribute to their vulnerability to affective disorders. Estrogen replacement therapy might decrease this vulnerability and might add to the efficacy of serotonergic antidepressants when warranted.

Teaching normal and abnormal behavior to primary care physicians

OBJECTIVE

This article delineates the framework for a curriculum on psychiatry, normal and abnormal human behavior for primary care physicians (PCPs).

METHODS

Curricula have been surveyed. Members of the Education Committee of the Association of Medicine and Psychiatry, as well as Family Physicians and General Internists involved in education have been consulted. Their recommendations are integrated.

RESULTS AND CONCLUSIONS

The curriculum should be developed according to the needs of PCPs and from their perspective. Patient and problem-oriented, its content can be divided into: a) personal skills that should be developed; and b) knowledge of symptoms, their differential diagnosis (DDX) and management within the PCP's, facilities and abilities.

Increased imidazoline and alpha 2 adrenergic binding in platelets of women with dysphoric premenstrual syndromes

An association between dysphoric premenstrual syndromes (PMS) and a lifetime history of major depressive disorders has previously been documented. Other studies have demonstrated an increase in the binding of radiolabeled imidazoline compounds to platelets of depressed patients. Clonidine and related imidazoline compounds interact with alpha 2 adrenoceptors to inhibit neuronal noradrenergic activity and in higher concentrations, they stimulate noradrenergic activity through their interaction with imidazoline receptors. Here we report increased 3H para-aminoclonidine binding to high affinity alpha 2 adrenoceptor sites as well as to nonadrenergic imidazoline binding sites in platelets of women with dysphoric PMS. This higher binding was most pronounced during the late-luteal-symptomatic phase of the menstrual cycle and, to a lesser degree, during the non-symptomatic mid-follicular phase. Binding to the imidazoline site distinguished women with dysphoric PMS from women with no such symptoms, was highly positively correlated with the severity of symptoms, and was negatively correlated with plasma levels of progesterone. These findings suggest that platelet imidazoline binding sites might be a biological marker for dysphoric states in PMS or for the vulnerability to develop them. These findings also point to a possible biological link between dysphoric PMS and major depressive disorders.

The multiple interactional biological processes that might lead to depression and gender differences in its appearance

Several neurotransmitter systems have been implicated in the pathophysiology of depression. Gender differences have been demonstrated in some functions that involve these systems, mostly norepinephrine, serotonin, dopamine and acetylcholine. Several hormonal systems have been shown to be altered in depression and gender differences were demonstrated in their activity as well, notably in thyroid hormones and the hypothalamic-pituitary-adrenal system. Most gender differences in brain systems and their hormonal modulators might be attributed to developmental and state influences of gonadal hormones. It is suggested that gender differences in mechanisms that might underlie formation of depressive symptoms might be related mostly to interactional processes and destabilization of balance among multiple factors or circuitry in the central nervous system. Indeed, gender differences in specific neurotransmitters and hormonal systems can be demonstrated as well.

Menstrually Related Disorders: points of consensus, debate, and disagreement

It seems that during the past decade we have been witnessing an evolution of a consensus on the phenomenology and time course of various types of MRDs. We are in a stage in which definitions and diagnostic criteria can be developed, but their broad acceptance is still not assured. The etiology and pathophysiology are still fiercely debated, but reasonable and feasible methods for scientific elucidation of the various hypotheses are in place and are followed by solid groups. Despite the uncertainty concerning the etiology of MRDs, reasonably efficient treatment modalities do exist, and most sufferers of MRDs should expect an eventual alleviation of their symptoms if they are treated in a specialized, established, and up-to-date program.

Prolactin response to electroconvulsive shock in anesthetized rats

Serum prolactin level (SPL) of anesthetized rats was measured in response to electroconvulsive shock (ECS). This measurement served as an indicator of dopaminergic and serotonergic activity. Such neurotransmitter activity was modulated by pretreatment with cyproheptadine, parachlorophenylalanine (PCPA), pimozide, bromocriptine or L-dopa. A statistically significant lowered SPL was found in rats given ECS plus antiserotonergic agents, in comparison with animals receiving antiserotonergic agent or ECS alone. When ECS was administered to rats pretreated with the dopaminergic blocker, pimozide, there was a significant decrease in SPL, compared with animals receiving pimozide alone. When the dopaminergic system was stimulated by dopamine agonists, there was no elevation of SPL in response to ECS. Thus, there may be a balance between serotonergic and dopaminergic systems. The agents used in the experiment may upset this balance and produce a change in prolactin response to a given ECT stimulus.