February 2011

Feb
2011
Vol. 23. No. 1

EDITORIAL

Meetings, new data, thorough reviews, and farewell to a friend

The upcoming meeting of the American Academy of Clinical Psychiatrists in collaboration with Current Psychiatry will take place in Chicago, Il, on April 15-17, 2011. The meeting’s topic is “Psychotic and cognitive disorders: Solving clinical challenges, improving patient care.” Presentations will address psychotic and cognitive disorders across the lifespan, best practices for treatmentresistant schizophrenia, managing dementia pharmacologically and behaviorally, evaluating risk for violence and suicide, and treating psychotic disorders during pregnancy and postpartum. New to this meeting will be a “point/ counterpoint” exchange on antipsychotics (“Efficacy vs tolerability: Which trumps?”) between Drs. Henry A. Nasrallah and Rajiv Tandon. This will be a great meeting, and I hope all of you will attend.

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ORIGINAL RESEARCH

A 6-month follow-up of imaginal desensitization plus motivational interviewing in the treatment of pathological gambling

Jon E. Grant, JD, MD, MPH | Christopher B. Donahue, PhD | Brian L. Odlaug, BA | Suck Won Kim, MD

BACKGROUND: Pathological gambling (PG), a disabling disorder experienced by approximately 1% of adults, has few empirically validatedtreatments. A recent study demonstrated that 6 sessions of imaginal desensitization plus motivational interviewing (IDMI) was effective in achieving abstinence for a majority of individuals with PG. This study sought to examine whether those benefits were maintained 6 months post-treatment.


METHODS: Sixty-eight individuals who met DSM-IV criteria for PG were randomly assigned to 6 sessions of IDMI or Gamblers Anonymous (GA) referral over an 8-week period. Participants who failed to respond to GA were offered IDMI after the 8-week acute treatment period. All individuals who responded to IDMI were contacted after 6 months and assessed with measures of gambling severity and psychosocial functioning.


RESULTS: Forty-four participants completed 6 sessions of IDMI (25 initially assigned to IDMI and 19 to GA). Thirty-five of the 44 (79.5%) responded during acute treatment, and all 35 were available for a 6-month evaluation. All gambling severity scales maintained statistically significant gains from baseline, although some measures showed significant worsening compared with post-IDMI treatment.


CONCLUSIONS: Six sessions of IDMI resulted in statistically significant reductions in PG urges and behavior, which were largely maintained for 6 months.

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Telephone-administered cognitive-behavioral therapy for clients with depressive symptoms in an employee assistance program: A pilot study

Raymond W. Lam, MD | Kevin Lutz, BA | Melady Preece, PhD | Paula M. Cayley, MSW | Anne Bowen Walker, MSW

BACKGROUND: To assess the clinical and work productivity effects of a brief intervention using telephone-administered cognitive-behavioral therapy (CBT) for clients with depressive symptoms attending an employee assistance program (EAP).


METHODS: Self-referred clients attending the PPC Canada EAP with clinically relevant depressive symptoms at initial assessment were offered an 8-session telephone-administered CBT program. Outcomes before and after intervention were assessed with the 9-item Personal Health Questionnaire (PHQ-9), Global Assessment of Functioning (GAF), and clinician ratings of work absence and performance impairment.


RESULTS: Fifty clients were referred to the pilot program; 39 participated and 31 completed the telephone CBT program. Among program participants, there was significant improvement in PHQ-9 and GAF scores. There was also a significant reduction in performance impairment but not work absence. Anecdotal reports indicated high satisfaction ratings among participants.


CONCLUSIONS: The results of this pilot study, although limited by the absence of a comparison or control group, suggest that a brief telephoneadministered CBT program can improve depressive symptomatology, work productivity, and general function in depressed clients attending an EAP. Further controlled studies are needed to confirm these preliminar findings.

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Lamotrigine plus quetiapine combination therapy in treatment-resistant bipolar depression

Yong M. Ahn, MD, PhD | Jennifer Y. Nam, MSW | Jenifer L. Culver, PhD | Wendy K. Marsh, MD | Julie C. Bonner, MD | Terence A. Ketter, MD

BACKGROUND: Lamotrigine and quetiapine are commonly used in bipolar disorder, but there are no published systematic studies of their use in combination for treatment-resistant bipolar depression.


METHODS: We studied 39 trials in outpatients (15 with bipolar I disorder, 22 with bipolar II disorder, and 1 with bipolar disorder not otherwise specified; 1 patient had 2 trials) with depression resistant to quetiapine or lamotrigine who were taking a mean of 1.7 other prescription psychotropic medications. Patients were given either open-label lamotrigine or quetiapine naturalistically, for up to 12 weeks of combination therapy.


RESULTS: Lamotrigine (mean dose, 204.2 mg/d) plus quetiapine (mean dose, 188.5 mg/d) increased the euthymia rate (0.0% to 46.2%), decreased syndromal (79.5% to 30.8%) and subsyndromal (20.5% to 15.4%) depression rates, and improved Clinical Global Impression-Severity (mean change, –1.0) and Global Assessment of Functioning (mean change, +5.9)  scores. Approximately one-fifth of patients discontinued therapy (20.5%) or required subsequent additional pharmacotherapy (20.5%). Only 10.3% discontinued due to adverse effects, and there was no significant change in mean body weight.


CONCLUSIONS: The findings of this uncontrolled open pilot study must be viewed with caution. However, randomized, double-blind, placebocontrolled studies are warranted to confirm the possibility that combination therapy with lamotrigine and quetiapine is effective and well tolerated in patients with treatment-resistant bipolar depression.

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Misdiagnosis of bipolar disorder in children and adolescents: A comparison with ADHD and major depressive disorder

Jagan K. Chilakamarri, MD | Megan M. Filkowski, BA | S. Nassir Ghaemi, MD

BACKGROUND: Controversy surrounds the frequency of underdiagnosis vs overdiagnosis of bipolar disorder (BD) in children and adolescents compared with diagnoses of attention-deficit/hyperactivity disorder (ADHD) and major depressive disorder (MDD).


METHODS: Sixty-four children and adolescents (age 7 to 18) treated in a community setting were systematically assessed for diagnostic and treatment histories. Best estimate consensus diagnosis was made using DSMIV criteria.


RESULTS: ADHD was overdiagnosed (all patients with ADHD had received the diagnosis, as did 38% of patients with MDD and 29% of patients with BD, respectively), while MDD was partially underdiagnosed and partially overdiagnosed (57% of MDD patients received the diagnosis, 43% did not; 33% of patients with BD were incorrectly diagnosed with MDD). BD was underdiagnosed, not overdiagnosed (38% received the diagnosis, 62% did not; BD was not diagnosed in the ADHD sample, and in only 5% of the patients with MDD). The absence of a positive family history predicted misdiagnosis of BD (relative risk = 2.48, 95% confidence interval 1.10 to 5.56). Observational treatment response to stimulants was equally high in all groups (75% to 82%).


CONCLUSIONS: In the first controlled study on this topic, BD was not overdiagnosed in children and adolescents, as it is often claimed, and ADHD was. Stimulant response was nonspecific and diagnostically uninformative. Studies with larger samples are needed to replicate or refute these results.

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