August 2011

Vol. 23. No. 3


Proposed DSM-5 revisions to personality disorder criteria need further scrutiny

The announced 2013 publication date for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders draws closer. DSM-5 has been  greatly anticipated, but also heavily criticized. The process has been said to lack transparency, many of the proposed changes have been criticized for lacking an evidence base, and the field trials are behind schedule. I recently participated in a discussion with Mark Zimmerman, MD, which will be published in an upcoming issue of Current Psychiatry, regarding the personality disorder (PD) category. Dr. Zimmerman points out the committee offers no evidence their proposed criteria—which will eliminate 4 of the 10 PDs—perform better than the current criteria. Disturbingly, Dr. Zimmerman also points out there is no plan to directly compare the proposed criteria against current criteria. There is a push to include an overly complex dimensional rating system that likely will be ignored by all but the most scrupulous practitioners, and risks further marginalizing the category. Can you imagine another medical specialty that simply eliminates diagnoses by committee fiat? This is not the way to go about revising such an important diagnostic system…



Lack of replication of the association of low serum cholesterol and attempted suicide in another country raises more questions

Jose de Leon, MD | Paula Mallory, RD | Lorraine Maw, MA | Margaret T. Susce, RN, MLT | M. Mercedes Perez-Rodriguez, MD | Enrique Enrique Baca-Garcia, MD

BACKGROUND: In 2 Spanish case-control studies, low cholesterol levels in males were consistently associated with suicide attempts.

METHODS: This US study tried to replicate the association between low cholesterol levels and suicide attempts, using a case-control design to study all patients admitted to Eastern State Hospital in Lexington, Kentucky, during a 1-year period. Psychiatric patients who had currently attempted suicide were studied as cases, and psychiatric patients who had not currently attempted suicide served as controls. A fasting serum total cholesterol <160 mg/dL was considered a possible risk factor for suicide. Logistic regression provided an adjusted estimate of the univariate odds ratios (ORs) for confounding factors.

RESULTS: There were 193 current suicide attempters (cases) and 1091 non–current suicide attempters (controls). In the total sample logistic regression model, low cholesterol levels were significantly associated with lower risk of current suicide attempt (OR, 0.60; confidence interval (CI), 0.39 to 0.92) after adjusting for confounding variables. After sex stratification, low cholesterol levels were significant only among men (OR, 0.47; CI, 0.26 to 0.86). This US study did not replicate our prior Spanish findings; to the contrary, low cholesterol levels were not associated with increased suicide risk but with a decreased risk in US men.

CONCLUSIONS: It is possible cholesterol abnormalities and low body mass index may be markers of suicide risk, particularly in some male patients.


Assessing depression and factors possibly associated with depression during the course of Parkinson’s disease

Amy Farabaugh, PhD | Joseph J. Locascio, PhD | Liang Yap, PhD | Maurizio Fava, MD | Stella Bitran, PhD | Jessica L. Sousa, BA | John H. Growdon, MD

BACKGROUND: Although research suggests depression is common among individuals with Parkinson’s disease (PD), it is unclear how to best assess depression in PD (dPD). We wanted to examine the prevalence of dPD using different definitions of depression, as well as examine factors associated with dPD.

METHODS: One hundred fifty-eight individuals (68% male; age 66.8 ± 9.6 SD) with a primary diagnosis of PD were assessed for depression using the Harvard Department of Psychiatry/National Depression Screening Day Scale (HANDS) in an outpatient setting at the Movement Disorders Clinic at Massachusetts General Hospital. We defined depression using 4 thresholds\ based on the HANDS and whether or not an individual was ever on an antidepressant regimen. We also examined potential predictors of the presence of dPD.

RESULTS: The prevalence of depression among study participants ranged from 11% to 57%, depending on which of the 4 definitions of depression was applied. Younger age and longer duration of PD predicted a relatively higher prevalence of depression. Having a history of depression prior to onset of PD also was predictive of dPD.

CONCLUSIONS: Depression appears to be relatively common among individuals  with PD, and history of depression, younger age, and longer PD duration may be factors associated with dPD.


Effects of continuity of care and patient dispositional factors on the physician-patient relationship

Russell Noyes, Jr., MD | Oladipo A. Kukoyi, MD | Susan L. Longley, PhD | Douglas R. Langbehn, MD, PhD | Scott P. Stuart, MD

BACKGROUND: We developed a questionnaire to examine the influence of physician and patient variables on the quality of the physician-patient relationship.

METHODS: More than 300 family medicine patients completed self-report measures of the physician-patient relationship and variables likely to influence it.

RESULTS: The quality of relationship was related to continuity of physician care (having a primary physician, duration of that relationship, and frequency of visits) and to patient dispositional variables (neuroticism, positive and negative affectivity) but not to demographic variables. The regression model included having a primary physician, duration of relationship with that physician, and positive affectivity. Relationship quality was, in turn, associated with outcomes (adherence to care, treatment response, satisfaction with care, and commitment to physician).

CONCLUSIONS: The quality of physician-patient relationship is influenced by physician continuity and patient dispositional variables. Better understanding of these may contribute to the therapeutic potential of this important relationship.


Long-term worsening of bipolar disorder related with frequency of antidepressant exposure

Sergio A. Strejilevich, MD | Diego J. Martino, MD | Eliana Marengo, MD | Ana Igoa, MD | Guillermo Fassi, MD | Jeannie B. Whitman, PhD | S. Nassir Ghaemi, MD

BACKGROUND: The aim of this study of 53 persons with bipolar disorder (BD) was to evaluate the relationship between history of exposure to antidepressants (AD) and mood stabilizers (MS) and the percentage of time spent ill.

METHODS: BD outpatients with more than 12 months of prospective follow- up were included. Outcome was documented using a life charting technique. Current and previous exposure to AD and MS were assessed using a scale that provides a quantitative measure of exposure to psychotropic medications. Regression models were used to correct for possible confounders.

RESULTS: Previous treatment with AD was an independent predictor of polarity changes (P < .001) and mixed symptoms (P = .01). In contrast, “years of exposure to MS” was an independent predictor of time spent asymptomatic (P = .019). The ratio between exposure to AD vs MS was associated with less weeks asymptomatic (P = .03), more mixed symptomatology (P = .019), and more polarity changes (P = .001).

CONCLUSIONS: Antidepressant exposure was a major predictor of mood instability in the long-term outcome of BD. The ratio used of previous exposure to AD vs MS was associated with poor outcomes, suggesting that the harmful effect of AD may be additive and related to how much they are used.