August 2014

Vol. 26. No. 3


Practicing psychiatrists need clinical research, not mindless neuroscience

I have become concerned about the growing focus on mindless neuroscience in many prominent psychiatric journals. Many journals, in my view, are no longer interesting or reader-friendly. In fact, many articles simply are not understandable to ordinary readers. These journals gradually have become more narrowly focused on the neurosciences—in particular brain imaging and molecular genetics—to the exclusion of more general interest articles involving clinical and translational science. This situation has developed although few clinically useful findings have emerged from neuroscience. Leaders at the National Institutes of Health are preoccupied by neuroscience research and have targeted enormous funds to these efforts. Funding in the more traditional areas of research, such as epidemiology, cognitive science, and treatment, have languished— although these findings are useful to clinicians (eg, a well-designed clinical trial). In 2004, Thomas Insel, director of the National Institute of Mental Health, dismantled the Basic Behavioral and Social Science Branch, which was considered integral to basic psychiatric research. In 2013, the Obama administration announced that $100 million “Brain Initiative” to study brain function. Although laudable, I have concerns that funds will be siphoned from otherwise meritorious clinical projects to further the work of a small number of neuroscientists…



Obstructive sleep apnea and risk for late-life depression

Siddharth Bajpai, MD | Kyoung Bin Im, MD | Mark Eric Dyken, MD | Simrit K. Sodhi, BS | Jess G. Fiedorowicz, MD, PhD

BACKGROUND: Obstructive sleep apnea (OSA) is a sleep-related breathing disorder characterized by repetitive pharyngeal collapse. Because of the association between OSA, ischemia, and late-life depression, we hypothesized that older patients with OSA would have a higher prevalence of depression relative to their younger counterparts.

METHODS: We retrospectively reviewed charts of patients evaluated at the Sleep Disorders Center (SDC) at University of Iowa Hospitals and Clinics. A total of 617 patients age ≥18 seen at SDC for diagnostic and therapeutic sleep studies were identified. Patients with a chart diagnosis of depressive disorder or treatment with antidepressants were identified as having a depressive disorder. Patients with an Apnea/Hypopnea Index ≥5 were identified as having OSA.

RESULTS: No evidence of an escalating prevalence of depression with age was found in patients with OSA relative to those without the disorder. Prevalence of depression was similar in the OSA and the nonapnea groups (40.9% vs 40.3%, respectively; χ2 = 0.02; df = 1; P = .89). Individuals with OSA had a significantly higher body mass index and greater number of chart diagnoses of hypertension, diabetes mellitus, and coronary artery disease compared with the nonapnea group.

CONCLUSIONS: The prevalence of depression among individuals with OSA does not appear to be moderated by age. Similarly high rates of depression were observed across the population of individuals referred for sleep studies, whether or not they were diagnosed with OSA.


Psychological distress, job dissatisfaction, and somatic symptoms in office workers in 6 non-problem buildings in the Midwest

Christopher F. Manlick, BA | Laurence J. Fuortes, MD | Matthew A. Stein, MS | P. Subramanian, PhD | Peter S. Thorne, PhD | Stephen J. Reynolds,, PhD

BACKGROUND: Researchers examined office worker characteristics and reports of non-specific somatic symptoms in 6 non-problem buildings in the Midwestern United States.

METHODS: We assessed office workers for demographic characteristics and somatic symptoms that occurred in the workplace. Sampling was conducted over a 1-week period in each building over 4 seasons. Our team administered the Medical Outcome Survey questionnaire, the Brief Symptom Inventory, and the Job Content Questionnaire to individuals at each site, comparing office workers reporting no symptoms to those reporting ≥4 symptoms.

RESULTS: Self-reported nonspecific somatic symptoms were frequent in office workers in non-problem buildings. High symptom levels were associated with younger age, female sex, psychological distress, impaired quality of life, and poor job satisfaction.

CONCLUSIONS: The findings suggest that office workers frequently report somatic symptoms they believe are related to the workplace even in buildings considered non-problematic. People with high symptom levels perceived as related to the workplace are psychologically distressed, have impaired quality of life, and feel dissatisfied and powerless in the workplace.


A single-blind study of ‘as-needed’ ecopipam for gambling disorder

Jon E. Grant, JD, MD, MPH | Brian L. Odlaug, PhD, MPH | Timothy Fong, MD | Margarit Davtian, BA | Richard Chipkin, PhD | Suck Won Kim, MD

BACKGROUND: Gambling disorder is a disabling illness experienced by 1% to 3% of adults. Pharmacologic management of gambling disorder has produced mixed results, with some but not all studies showing medication to be more effective than placebo. Ecopipam may offer promise for treating gambling disorder because of its antagonism of dopamine-1 receptors.

METHODS: Twenty-eight indviduals with gambling disorder were enrolled and received ≥1 dose of oral ecopipam in an 8-week trial (1 week placebo lead-in, 6 weeks of medication (50 to 100 mg/d as needed), and 1 week follow-up. Participants were enrolled between September 2010 and June 2011 at 3 sites in the United States. Change from baseline to study endpoint on the Yale-Brown Obsessive Compulsive Scale Modified for Pathological Gambling (PG-YBOCS) was the primary outcome measure.

RESULTS: Treatment was associated with statistically significant reductions in the PG-YBOCS total score (baseline score of 25.6 reduced to 14.0 at study endpoint; P < .001) and PG-YBOCS subscales (Thought-Urge and Behavior, P < .001).

CONCLUSIONS: These findings suggest that pharmacologic targeting of the dopamine-1 receptor may be beneficial in gambling behavior. Placebocontrolled, double-blind studies are warranted to confirm these preliminary findings.


Capgras delusion with violent behavior in Alzheimer dementia: Case analysis with literature review

Kenneth R. Kaufman, MD, MRCPsych | Neil B. Newman, BA | Alveena Dawood, BS, MBS

BACKGROUND: Capgras delusion (CD) has multiple etiologies including neurodegenerative disorders and can be associated with violent behavior. CD is a common complication of Alzheimer dementia (AD); however, CD with violent behavior is uncommon in AD. We report escalating violent behavior by a patient with advanced AD and CD who presented to the emergency department (ED) and required admission to an academic medical center.

METHODS: Case analysis with PubMed literature review.

RESULTS: A 75-year-old male with a 13-year history of progressive AD, asymptomatic bipolar disorder, chronic kidney disease, hypertension, hyperlipidemia, and benign prostatic hypertrophy presented to the ED with recurrent/escalating violence toward his wife, whom he considered an impostor. His psychotropic regimen included potentially inappropriate medications (PIMs) for geriatric/AD patients—topiramate/amitriptyline/ chlordiazepoxide/olanzapine—that are associated with delirium, cognitive decline, dementia, and mortality. Renal dosing for topiramate, reduction in PIMs/anticholinergic burden, and substituting haloperidol for olanzapine resolved his violent behavior and CD.

CONCLUSIONS: CD in AD is a risk factor for violent behavior. As the geriatric population in the United States grows, CD in patients with AD may present more frequently in the ED, requiring proper treatment. Pharmacovigilance is necessary to minimize PIMs in geriatric/AD patients. Clinicians and other caregivers require further education to appropriately address CD in AD.