August 2010

Aug
2010
Vol. 22. No. 3

EDITORIAL

Where we are and where we need to be: Keeping our focus on clinical practice

I begin this editorial with the sad news that Dr. Elizabeth Weller passed away last year (her obituary is on page 147). She was a long-time member of the American Academy of Clinical Psychiatrists (AACP) and an exceptional member of Annals of Clinical Psychiatry’s editorial board. I had the privilege of knowing Dr. Weller, and she will be greatly missed. 

I want to call Annals readers’ attention to Dr. Henry A. Nasrallah’s editorial in the April 2010 issue of Current Psychiatry.1 His “manifesto” is one of the best summaries of the role and function of modern psychiatry that I’ve seen, although much of it will not be controversial to this audience. His “living document” proposes that psychiatry is a “medical specialty that focuses on brain disorders or behavior, thought, mood, cognition, and conation” and that psychiatrists must be “fully trained physicians.” Further, he acknowledges our shortcomings—including the inconvenient facts that diagnoses are more reliable than valid and that many of our treatments are based on serendipity. His manifesto is worth reading.

In this issue, we have a great collection of articles. We begin with a review by Annals board member Subramoniam Madhusoodanan, MD, and colleagues on extrapyramidal symptoms (EPS) associated with antidepressants. Most of us learn that EPS only develop with antipsychotic use, but their review reminds us that these symptoms sometimes occur with antidepressants. After more than 50 years of antidepressant usage, we still know little about response predictions, but Amy Farabaugh, PhD, and colleagues help fill this gap by showing that early improvement in anger/hostility helps predict treatment response. In this vein, my colleague Jess G. Fiedorowicz, MD, MS, and coworkers look at neuroticism as a predictor of response to escitalopram. Maren Nyer, MEd, and colleagues discuss the positive role that marriage has for enhancing quality of life for patients with schizophrenia/schizoaffective disorder, and show once again the power of intimate relationships for maintaining mental health. Roy R. Reeves, DO, PhD, and his group discuss unrecognized physical symptoms prompting psychiatric admission, alerting us to the need to be vigilant when assessing a patient’s physical status. In a timely communication, Phebe Tucker, MD, and colleagues find high cortisol levels in survivors of the 1995 Oklahoma City bombing with posttraumatic stress disorder, showing the power that traumatic events have on the long-term course of stress systems. Continuing their series of articles on attention-deficit/hyperactivity disorder (ADHD) that began in the May 2010 issue of Annals, Barrie K. Marchant, MS, and colleagues show that personality disorder symptoms interfere with response to OROS methylphenidate in adults with ADHD. Rounding out the issue, Adrian Palominao, MD, and colleagues present 2 case reports of reversible leukocytosis after lithium and clozapine combination therapy. 

We are in the early stages of planning the next joint AACP/Current Psychiatry meeting set for April 2011 in Chicago, IL, with the theme of psychotic and cognitive disorders. Both organizations are committed to educating psychiatrists through stimulating and thought-provoking meetings. We will keep Annals readers informed of the meeting as planning proceeds.

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Elizabeth B. Weller, MD: August 7, 1949 – November 29, 2009

Elizabeth B. Weller, MD, long-time member of Annals of Clinical Psychiatry’s editorial board, succumbed to breast cancer on November 29, 2009, shortly after her sixtieth birthday. At the time of her death, Elizabeth was professor of psychiatry and pediatrics at the University of Pennsylvania (the first woman holding an endowed professorship at the university) and the first chair of the department of child and adolescent psychiatry at Children’s Hospital of Philadelphia.

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ORIGINAL RESEARCH

Neuroticism but not omega-3 fatty acid levels correlate with early responsiveness to escitalopram

Jess G. Fiedorowicz, MD, PhD | Nancy Hale, BS, RN | Arthur A. Spector, MD | William H. Coryell, MD

Background: Omega-3 fatty acid (O3FA) levels and dimensional personality measures have been associated with major depression and the course of depressive illness. We sought to study the utility of O3FA levels and dimensional personality measures as predictors of early improvement with escitalopram.

Methods: Twenty-four participants were enrolled in an open-label trial of escitalopram 10 mg/d for 4 weeks. Baseline erythrocyte O3 levels and dimensional personality assessments were obtained.

Results: Using a conservative, intention-to-treat analysis, baseline neuroticism (r = –0.57; P = .007), as measured by the Revised NEO Personality Inventory but not erythrocyte O3 levels, was correlated with improvements on escitalopram. A facet analysis of the neuroticism domain showed the relationship with antidepressant response to be focused on trait anxiety (r = –0.65; P = .002).

Conclusions: Anxiety may have important prognostic implications on subsequent response to selective serotonin reuptake inhibitors, such as escitalopram.

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Early improvements in anxiety, depression, and anger/hostility symptoms and response to antidepressant treatment

Amy Farabaugh, PhD | Shamsah Sonawalla, MD | Daniel P. Johnson, BA | Janet Witte, MD, MPH | George I. Papakostas, MD | Tracie Goodness, BA | Alisabet Clain, MS | Lee Baer, PhD | David Mischoulon, MD, PhD | Maurizio Fava, MD | Rebecca Harley, PhD

Background: The purpose of this study was to examine whether treatment response to fluoxetine by depressed outpatients was predicted by early improvement on any of 3 subscales (Anxiety, Depression, and Anger/Hostility) of the Symptom Questionnaire (SQ).

Methods: We evaluated 169 depressed outpatients (52.6% female) between ages 18 and 65 (mean age, 40.3 ± 10.6 years) meeting DSM-IIIR criteria for major depressive disorder (MDD). All patients completed the SQ at baseline (week 0) and at weeks 2, 4, and 8 of treatment with fluoxetine 20 mg/d. We defined treatment response as a ≥50% reduction in score on the 17-item Hamilton Rating Scale for Depression, and early improvement on 3 SQ subscales (Anxiety, Depression, and Anger/Hostility) as a >30% reduction in score by week 2.

Results: The percentage of patients with significant early improvement in anger was significantly greater than the percentage of those with early improvements in anxiety or depression. When early improvement on the Anxiety, Depression, and Anger/Hostility subscales of the SQ were assessed independently by logistic regression, all 3 subscales were predictors of response to treatment.

Conclusions: Early improvement in anger, anxiety, and depressive symptoms may predict response to antidepressant treatment among outpatients with MDD.

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The relationship of marital status and clinical characteristics in middle-aged and older patients with schizophrenia and depressive symptoms

Maren Nyer, PhD | John Kasckow, MD, PhD | Ian Fellows, MS | Edith C. Lawrence, PhD | Shah Golshan, PhD | Ellen Solorzano, MSW | Sidney Zisook, MD

Background: This study examines the relationship of marital status to depression, positive and negative symptoms, quality of life, and suicidal ideation among 211 patients with schizophrenia-spectrum disorders and subsyndromal depressive symptoms. We hypothesized that single participants would have more severe symptomatology than married and cohabitating participants.

Methods: Outpatients, age 40 or older, were diagnosed with schizophrenia or schizoaffective disorders using the MINI Structured Clinical Interview for DSM-IV Axis 1 Disorders. Participants exhibited a score of >8 on the Hamilton Rating Scale for Depression but did not meet criteria for a major depressive episode. 

Results: Participants who were married or cohabitating had a later age of onset of first psychotic episode or hospitalization than those who were single (age, 29.35 vs 24.21). Married participants rated their quality of life higher than those who were single (mean Quality of Life Scale scores, 72.28 vs 53.87) and had less suicidal ideation than those who were divorced, widowed, or separated (7.4% vs 29.2%).

Conclusions: In middle-aged and older individuals with schizophrenia or schizoaffective disorder and depressive symptoms, marriage appeared to enhance quality of life and protect against suicidal ideation. Efforts that focus on providing additional support for those who are experiencing divorce or separation could prove to be lifesaving for these individuals.

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