Volume 73April 2012Number 4

In Memoriam

413 In Memoriam: Andrew C. Leon, PhD, 1951–2012

Review Articles

414 Nonsteroidal Anti-Inflammatory Drugs in Schizophrenia: Ready for Practice or a Good Start? A Meta-Analysis

Clinical Points
  • Nonsteroidal anti-inflammatory drug (NSAID) augmentation to antipsychotic medication can potentially improve both positive and negative symptoms, but more research is needed before this can be implemented in clinical practice.
  • The 5 randomized controlled trials included in this meta-analysis did not show increased side effects of NSAID augmentation as compared to placebo, but longer application (ie, years) may induce side effects, especially on the stomach.
  • Augmentation with aspirin may have the additional benefits of reducing cardiovascular and cancer mortality, which are both increased in patients with schizophrenia.


486 Are Antipsychotics or Antidepressants Needed for Psychotic Depression? A Systematic Review and Meta-Analysis of Trials Comparing Antidepressant or Antipsychotic Monotherapy With Combination Treatment

Clinical Points
  • Available evidence supports the use of antidepressant-antipsychotic combination treatment, rather than monotherapy with either an antipsychotic or antidepressant, for the acute management of psychotic depression.
  • Data on specific antidepressant-antipsychotic combinations for the acute management of psychotic depression are too limited to allow for more detailed recommendations at this time.
  • Evidence is lacking regarding the relative efficacy of antidepressant-antipsychotic combinations compared to monotherapy with either an antipsychotic or antidepressant for relapse prevention after an acute episode of psychotic depression.


Original Research

420 Neural and Behavioral Correlates of Peritraumatic Dissociation in an Acutely Traumatized Sample

Clinical Points
  • Peritraumatic dissociation is a risk factor for the development of posttraumatic stress disorder and can help to determine who is at risk and should thus be offered close monitoring or early interventions in the acute period following a traumatic event.
  • Peritraumatic dissociation therefore constitutes an important marker that should be routinely assessed shortly after the traumatic event.
  • Subjects who experience peritraumatic dissociation are most likely to exhibit persistent dissociation following the traumatic event and may therefore require treatment that focuses on a reduction of dissociative processing.


427 Mortality of Neuroleptic Malignant Syndrome Induced by Typical and Atypical Antipsychotic Drugs: A Propensity-Matched Analysis From the Japanese Diagnosis Procedure Combination Database

Clinical Points
  • Clinicians can predict the prognosis of neuroleptic malignant syndrome in accordance with the causative drugs and with patient background and comorbidities.
  • Clinicians should pay attention to the possibility of neuroleptic malignant syndrome in all age groups while treating with antipsychotics.


431 Emotional Numbing in Posttraumatic Stress Disorder: A Functional Magnetic Resonance Imaging Study

Clinical Points
  • Many women with posttraumatic stress disorder (PTSD) experience a feeling of being emotionally numb.
  • Emotional numbing symptoms correlate with reduced dorsomedial prefrontal response during emotional processing, particularly during imagery of positive and negative social events.
  • Provided that current psychological treatments for PTSD are largely directed toward reexperiencing and avoidance symptoms, increased attention toward treatments for emotional numbing symptoms may be indicated.


445 An 8-Week, Randomized Controlled Trial of Atomoxetine, Atomoxetine Plus Buspirone, or Placebo in Adults With ADHD

Clinical Points
  • The short-term addition of buspirone to atomoxetine in adult ADHD was well tolerated.
  • Adding buspirone to atomoxetine for 8 weeks in nonanxious adult ADHD patients had minor overall effects but may benefit some patients.


451 Successful Pharmacologic Treatment of Major Depressive Disorder Attenuates Amygdala Activation to Negative Facial Expressions: A Functional Magnetic Resonance Imaging Study

Clinical Points
  • Only successful paroxetine treatment decreases amygdala activation.
  • This amygdala signal is inversely correlated with the activation of the pregenual anterior cingulate cortex.
  • These findings might change the interpretation of decreased amygdala activities after SSRI treatment in previous studies and suggest improved frontolimbic control as a requisite for clinical response.


460 Prediabetes in Patients Treated With Antipsychotic Drugs

Clinical Points
  • In 2010 the American Diabetes Association (ADA) published criteria for the identification of prediabetes, a term that indicates a high risk for the future development of diabetes mellitus: fasting plasma glucose level in the range of 100–125 mg/dL or a glycosylated hemoglobin (A1c) level in the range of 5.7%–6.4% or plasma glucose level in the range of 140–199 mg/dL 2 hours after the ingestion of 75 g of glucose.
  • Prediabetes was identified in 37% of psychiatric inpatients who were receiving antipsychotics.
  • Weight reduction through decreased caloric intake and increased physical activity is the keystone of the management of prediabetic state in this population.


478 Insomnia and Objectively Measured Sleep Disturbances Predict Treatment Outcome in Depressed Patients Treated With Psychotherapy or Psychotherapy-Pharmacotherapy Combinations

Clinical Points
  • Sleep problems are highly prevalent, often intractable symptoms that increase the risk of poor depression treatment response and recurrence.
  • Insomnia combined with objectively measured sleep disturbance may represent a biologically more severe phenotype of insomnia.
  • Treating sleep problems using empirically supported behavioral or pharmacologic interventions may play an important role in optimizing depression treatment and prevention efforts.


498 The Impact of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) on Prescribing Practices: An Analysis of Data From a Large Midwestern State

Clinical Points
  • The Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study was intended to provide antipsychotic medication effectiveness data to help clinicians make evidence-based decisions.
  • An analysis of a large Medicaid claims database suggests that CATIE publications have not yet had a major impact on prescribing to patients with schizophrenia.
  • It is important to increase efforts to help clinicians access, understand, and translate into clinical practice the findings of well-designed clinical trials.



437 Would Broadening the Diagnostic Criteria for Bipolar Disorder Do More Harm Than Good? Implications From Longitudinal Studies of Subthreshold Conditions

Discussion Points
  • The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnostic criteria are imperfect representations of an underlying behavioral, psychological, or biological dysfunction; thus, the criteria could be conceptualized as a type of test for the etiologically defined illnesses.
  • As with any other diagnostic test, diagnoses based on DSM-IV criteria produce some false positive and some false negative results.
  • The results of longitudinal studies suggest that lowering the diagnostic threshold for bipolar disorder will result in a greater increase in false positive than true positive diagnoses. This argues against lowering the diagnostic threshold for bipolar disorder.


443 Lowering the Diagnostic Threshold for Bipolar Disorder: The Wrong Stuff?

Discussion Points
  • Manic or hypomanic syndromes are defined by coherent constellations of interrelated signs and symptoms that involve changes in mood, energy, cognition, speech, behavior, and sleep.
  • Individual or subthreshold manic or hypomanic symptoms are not pathognomonic and should encourage a broad, rigorous differential diagnosis.


467 Pretest

CME Activity

476 Posttest


468 Tobacco Use Before, At, and After First-Episode Psychosis: A Systematic Meta-Analysis [Review Article]

For Clinical Use
  • Tobacco smoking is a risk factor for developing cardiovascular disease in patients with psychotic illness.
  • The prevalence of tobacco use before, at, and after the first episode of psychosis is around 60% and remains constant after the illness is established.
  • The initiation of tobacco use precedes the onset of psychosis by a mean of 5.3 years.
  • Ultrahigh-risk and first-episode psychosis patients are an ideal target for smoking cessation programs, which should be routinely offered in first-episode psychosis services.


Case Report

497 A Case of Akathisia After Switching From Branded to Generic High-Dose Olanzapine

Early Career Psychiatrists

504 New Clinical Drug Evaluation Unit (NCDEU) Annual Meeting: A Great Opportunity for Early Career Psychiatrists [Commentary]

506 The Psychiatric Manifestations of Mitochondrial Disorders: A Case and Review of the Literature [Review Article]

Clinical Points
  • Patients with mitochondrial disorders may present with psychiatric symptoms.
  • Many psychotropic medications can impair mitochondrial function or have side effects that may worsen medical conditions associated with mitochondrial disorders.
  • Psychiatrists should take a detailed personal and family medical history in all patients, appropriately investigate patients with suggestive clinical presentations, and be aware of the treatment implications of the diagnosis of a mitochondrial disorder.


513 Race and Long-Acting Antipsychotic Prescription at a Community Mental Health Center: A Retrospective Chart Review

Clinical Points
  • Ethnic minorities may disproportionately receive long-acting injection antipsychotics for treatment nonadherence.
  • Clinicians can improve adherence by considering effective psychotherapy modalities (individual, family, group) and oral antipsychotic regimens at optimal doses before prescribing long-acting injectables.
  • Clinicians should also screen for comorbid substance use, depression, or medication side effects in all patients to identify those at risk for nonadherence.


518 Can People With Nonsevere Major Depression Benefit From Antidepressant Medication? [Review Article]

Clinical Points
  • Antidepressants are effective for treating patients having nonsevere major depression.
  • The number needed to treat for antidepressants in patients with nonsevere major depression is robust.


526 Minimum Clinically Important Difference in the Positive and Negative Syndrome Scale With Data From the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE)

Clinical Points
  • The minimum clinically important difference is the smallest difference in a measure that patients or providers perceive as beneficial.
  • The minimum clinically important difference for the Positive and Negative Syndrome Scale (PANSS), the most commonly used measure of schizophrenic symptomatology, is approximately 15 points (34%) of baseline values.
  • The minimum clinically important difference in PANSS scores varies according to the baseline PANSS score.


533 d-Cycloserine Augmentation of Behavioral Therapy for the Treatment of Anxiety Disorders: A Meta-Analysis [Review Article]

Clinical Points
  • d-Cycloserine appears to enhance the effects of cognitive-behavioral therapy for anxiety disorders.
  • In contrast to a previous meta-analysis that combined results of animal and human studies, we found no significant effect of dose timing or number of doses on the efficacy of d-cycloserine.
  • Further trials are needed to clarify how the efficacy of d-cycloserine may differ between anxiety disorders and with prolonged use.


Letters to the Editor

538 Artifactual Rediagnosis of Psychotic Depression as Schizophrenia

Book Reviews

539 Developmental Disabilities From Childhood to Adulthood: What Works for Psychiatrists in Community and Institutional Settings

539 The Conceptual Evolution of DSM-5

540 Substance Abuse Disorders: Evidence and Experience

Psychiatrist.com Exclusives

Original Research

e541 Symptom Recurrence Following Intermittent Treatment in First-Episode Schizophrenia Successfully Treated for 2 Years: A 3-Year Open-Label Clinical Study

Clinical Points
  • After a single psychotic episode, most patients will experience symptom recurrence with reduction and discontinuation of treatment, even after 2 years of treatment.
  • Clinicians should be aware that onset of relapse may be abrupt and early warning signs may be short-lived.
  • At onset of relapse, symptom severity returns rapidly to levels close to those observed in the first psychotic episode.


e548 Prescribed Medication Availability and Deliberate Self-Poisoning: A Longitudinal Study

Clinical Points
  • Deliberate self-poisoning (DSP) patients have access to large amounts of prescribed medication and tend to ingest prescribed medication in their DSP episodes.
  • Current evidence best supports assessing the total medication load for the patients before commencing new treatment and being particularly vigilant for patients with a history of DSP.
  • In their assessment, clinicians should include availability of drugs in the household and encourage potentially suicidal patients to get rid of old drugs.


e555 Benzodiazepine Use Possibly Increases Cancer Risk: A Population-Based Retrospective Cohort Study in Taiwan

Clinical Points
  • This population-based study has shed light on a possible relationship between benzodiazepine use and an increased cancer risk.
  • Clinicians should consider the potentially increased cancer risk of benzodiazepine use in clinical practice.


e561 Clinical Expression of Bipolar Disorder Type I as a Function of Age and Polarity at Onset: Convergent Findings in Samples From France and the United States

Clinical Points
  • The initial presentation of bipolar disorder is mostly depressive and occurs early in adulthood.
  • The initial polarity of bipolar disorder is associated with subsequent polarity.
  • Both age and polarity at onset are associated with suicidal behavior and substance misuse.


e567 Effectiveness of Transcranial Magnetic Stimulation in Clinical Practice Post-FDA Approval in the United States: Results Observed With the First 100 Consecutive Cases of Depression at an Academic Medical Center

Clinical Points
  • Transcranial magnetic stimulation is a safe and effective adjunct to medication treatment of major depressive disorder.
  • Transcranial magnetic stimulation has here shown additional effectiveness in patients with depressions that are usually more difficult to treat, including those with bipolar disorder, high levels of medication resistance, or past nonresponse to treatment with electroconvulsive therapy.


Free Online Activities

e13 Treating ADHD: Addressing the Needs of College Students [CME]

e14 Early Recognition and Diagnosis of Multiple Sclerosis [CME]

e15 Bipolar Disorder Maintenance Treatment: Monitoring Effectiveness and Safety [CME]

e16 A Roadmap for the Management of Fibromyalgia [CME]

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