ObjectiveTo determine the impact of thyroid eye disease (TED) on patients in various stages of the disease.BackgroundTED is a debilitating and potentially sight-threatening inflammatory autoimmune disease that is frequently misdiagnosed. Challenging quality-of-life (QoL) issues can persist long after the active phase of disease has subsided.MethodsA 62-question survey was designed as a hypothesis-generating instrument to identify key issues confronting patients ≥18 years old with physician-diagnosed TED. Questions focused primarily on physical and emotional status, and QoL experiences in the 2 months prior to the survey. Data for individual questions are presented as summary statistics. Correlations between questions were determined using χ2 analyses.ResultsThe 443 respondents were 18 to >80 years old; >90% female, and >80% from the United States. Time since TED diagnosis ranged from <1 year to >10 years. Participants provided >500 free-form responses describing experiences of living with TED. Physical signs/symptoms were experienced by 307/443 (69%) patients. Of those responding to the QoL questions (N = 394), 53 (13%) reported symptoms improving, 73 (19%) reported symptoms worsening, and 255 (65%) reported no change in the 2 months prior to the survey. The most bothersome signs/symptoms were dry/gritty eyes, light sensitivity, bulging eyes, and pressure or pain behind the eyes. Respondents <60 years were significantly (p < 0.0001) more likely to report symptomatic TED than older patients. Of 394 respondents, 179 (45%) reported feeling depressed and/or anxious, 174 (44%) reported concern about their appearance, and 73 (19%) avoided public situations; 192 (49%) reported declines in confidence or feelings of general well-being, and 78 (20%) reported an inability to achieve goals. Activities limited by TED included reading, driving, and socializing. The proportion of respondents experiencing these negative QoL measures was higher when patients reported experiencing >5 symptoms, had been diagnosed within the last 5 years, or were <60 years of age.ConclusionsPhysical manifestations of TED impact QoL for patients through all phases of the disease. It is essential that physicians and healthcare professionals become more familiar with patient experiences such as those described here to better help patients manage their disease.

Back to table of contents Previous article Next article Reviewing the Clinical LandscapeFull AccessOur Most Fundamental TaskIra M. Lesser, M.D.Ira M. LesserSearch for more papers by this author, M.D.Published Online:16 Oct 2017https://doi.org/10.1176/appi.focus.154S05AboutSectionsView articleView PDFView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail View articleThe editors asked for “brief essays on interesting or key developments in psychiatry that practicing clinicians should be familiar with as they look ahead.” I would like to take a somewhat contrarian approach and focus on looking backward, with the goal of preserving, and even enhancing, aspects of training and practice, which, I believe, may receive less attention in our current therapeutic climate. In doing so, I feel somewhat like a curmudgeon but, I hope, like the character in the best-selling book A Man Called Ove (1), a curmudgeon with good intent.Having spent my entire four-decade career as a clinician, teacher, and administrator in an academic medical center, I have witnessed the advances but also have been disappointed in our ability to successfully treat major mental illness. In the past ten or so years, in psychopharmacology, we have not made much progress in translating our research into novel treatments. Although progress has been made in the use of neuromodulation technologies, these are expensive and not all that accessible to large groups of patients in desperate need. Our knowledge of imaging and genomics has exploded, but, again, their clinical application in psychiatry remains to be seen. We all are aware that patients suffering from mood disorders, schizophrenia, obsessive-compulsive disorder, posttraumatic stress disorder, and Alzheimer’s disease (to name just a few) often do not respond adequately to our state-of-the-art medications. Their suffering and that of their families are very evident.On the other hand, we have made progress with nonpharmacological approaches to the major mental illnesses, including evidence-based psychotherapies, such as cognitive-behavioral and dialectical behavior therapy, interpersonal therapy, trauma-focused therapy, acceptance and commitment therapy, family-focused therapy, and prolonged exposure therapy. And many experts in the treatment of psychotic disorders strongly believe that the psychosocial elements are equally or in some cases more important than medications to recovery and functional improvement.During my residency and in the first few years postresidency, the books that had the most influence on me (and continue to have their hold to this day) were Persuasion and Healing (2), by Jerome Frank; The Interpretation of Schizophrenia (3), by Silvano Arieti; The Technique and Practice of Psychoanalysis (4), by Ralph Greenson; and Existential Psychotherapy (5), by Irvin Yalom. Dr. Frank’s book gives an overall framework elucidating the basic elements of a healing relationship, irrespective of whether the healer is a psychiatrist or other mental health clinician, medicine man, shaman, or, I will add, a psychopharmacologist. I would not turn to Dr. Arieti’s book to understand the biology or pharmacotherapy of psychosis, but his painstaking work talking with psychotic patients and trying to understand their communications seems to be a lost art, but necessary for building a therapeutic relationship. Although I am neither an existential therapist nor a psychoanalyst, the latter two books focus on the therapeutic dyad and the need for the clinician to be in tune with the patient and his or her affective state and to be in the moment with the patient. Even Greenson’s book, although describing traditional analytic technique, includes chapters on the working alliance and the real relationship between the patient and the analyst that are applicable to many therapy settings today.I would venture to say that many of our current and recent trainees have not been exposed to (most of) these works. I have no problem with this, but I do have a problem with training that does not stress the fundamental importance of attention to the relationship. How many times have we heard residents state, “This is a medication case, not a psychotherapy case”? I know exactly what they mean, but the implication is that the relationship with a patient seen for medication is not a therapeutic one in the same sense as it is for a “psychotherapy” patient. I have often thought that the best psychopharmacologists I know also have wonderful psychotherapy skills. I have no data, but I would guess that the psychopharmacologist who does not truly engage a patient will do many one-time consultations with little follow-up.So, in trying to fulfill the editor’s wish to “look ahead,” I hope we do so with the understanding that healing is a process, often involving two people (although it certainly can involve more), where the healer must use skills over and above those specific to pharmacology, neuromodulation, virtual reality, deep brain stimulation, or whatever new treatment is shown to be helpful. And these skills are embedded in the relationship between healer and patient, as Frank so eloquently taught us.Dr. Lesser is professor of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, and chair of the Department of Psychiatry, Harbor–UCLA Medical Center.References1 Backman F: A Man Called Ove [English trans]. New York, Washington Square Press, 2013Google Scholar2 Frank JD: Persuasion and Healing. Baltimore, Johns Hopkins Press, 1967Google Scholar3 Arieti S: Interpretation of Schizophrenia, 2nd ed. New York, Basic Books, 1974Google Scholar4 Greenson R: The Technique and Practice of Psychoanalysis. vol. 1. New York, International Universities Press, 1967Google Scholar5 Yalom I: Existential Psychotherapy. New York, Basic Books, 1980Google Scholar FiguresReferencesCited byDetailsCited ByNone Volume 15Issue 4 Fall 2017Pages 5s-6sTreating the Invisible Wounds of War: Focus on PTSD and TBI

Ozao-Choy, Junko J. MD; Lesser, Ira MD; Dauphine, Christine E. MD, FACS; de Virgilio, Christian MD, FACS; Lee, Steven L. MD, FACS; Neville, Angela L. MD, FACS Author Information

Back to table of contents Previous article Next article Book ForumFull AccessRational Suicide in the Elderly: Clinical, Ethical, and Sociocultural AspectsIra M. Lesser, M.D.Ira M. LesserSearch for more papers by this author, M.D.Published Online:1 Jun 2017https://doi.org/10.1176/appi.ajp.2017.17030321AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail edited by Robert E. McCue, M.D., and Meera Balasubramaniam, M.D., M.P.H. New York, Springer, 2017, 224 pp., $109.00 (hardcover).Depending on one’s point of view, “rational suicide” can be seen as an oxymoron, an act of a person who has a mental illness, a philosophically and clinically justifiable act, an act against the principles of many religious groups, or an existential response to the vicissitudes of life. Rational Suicide in the Elderly, an edited volume of articles, addresses this topic from these and multiple other perspectives. The contributors include psychiatrists, psychologists, internists, oncologists, philosophers, anthropologists, public health experts, and theologians. The reader is taken on a historical tour of views about suicide; the philosophical basis underlying the search for meaning in life and for rationality in decision making; the psychodynamics of suicide; religious and anthropological views of suicide; and a possible antidote to the perceived demoralization, hopelessness, or loss of meaning through the medical use of hallucinogenic substances. In these articles, some of which are primarily theoretical, there are a number of chapters that take a more practical view, offering vignettes and providing clinicians with a framework for talking with individuals (who may or may not be patients) considering suicide, including the use of validated scales to further an understanding of the underlying factors leading to such a decision.The editors introduce the book with a disclaimer that they “do not espouse a particular point of view on whether suicide in the elderly can be rational” (pp. ix–x). They further state that “this book is about people who, without a clearly diagnosable mental illness, have made a well-considered decision to kill themselves” (p. x). In several chapters, criteria are given defining a desire for rational suicide as (1) resulting from a realistic assessment of the situation, (2) where the individual is unimpaired by psychological illness or severe emotional distress, and (3) where the motivational basis would be understandable to uninvolved observers. A major theme throughout the book is the question, “Is suicide always a sign of a mental disorder?” I believe that most readers will come away with the answer “no”; however, this is not the same thing as agreeing with someone’s request to kill oneself, and therein lies the dilemma that each provider has to decide for himself or herself.The book discusses the recent movement toward legislation in the United States and in some European countries to provide a legal framework for “assisted suicide.” In the United States, laws in states that have addressed this issue all are geared toward individuals who have a terminal illness and who do not have any mental disorder. For many, this may be a more understandable framework for considering a suicide to be “rational”: a terminal illness, often accompanied by pain and disability, with (allegedly) no hope for recovery. The rational suicide discussed in this book pertains more to people who do not have a terminal illness but who, nevertheless, do not wish to continue living. The concerns of these individuals, perhaps somewhat surprisingly, are similar to those of their peers who have a terminal illness (with the exception of pain control): loss of independence, autonomy, and dignity; the wish not to be a burden on others; and the loss of ability to enjoy activities. Some of the case histories discuss the elders’ view of their future as one where these concerns will rule their life, often not allowing them to have a “good death.”For the clinician, the most practical chapters (see the Kolva and Etter chapters) discuss the need and a framework for assessments from multiple perspectives. These include traditional psychiatric, cognitive, and suicide risk assessments; an assessment of decision-making capacity; an assessment of hopelessness and its relationship to a depressive disorder; and social support. I found the discussion of “desire for hastened death,” taken from the psycho-oncology and chronic disease literature, an interesting conceptual approach to thinking about rational suicide. The chapters titled “Can Suicide Be Rational?”, “Life’s Meaning and Rational Suicide,” and “Spirituality, Religion and Rational Suicide” have a much more theoretical orientation. The chapter on hallucinogens draws on recent carefully designed studies in terminally ill patients and in subjects seeking a psycho-spiritual experience, all of which had positive results in terms of psychological well-being, albeit in a generally younger population.I would have liked to see a discussion of the thought processes, internal psychological conflicts, and responses of clinicians who are engaged in discussions of rational suicide with older adults. I found myself staking out different positions as I read the book, highlighting the charged and multiple issues raised throughout. My feelings were captured by the last sentences of the book, “We are forever trying to catch the mists of human existence in the butterfly nets of our concepts; we demand categorical answers where there are only matters of degree. Nowhere is this more in evidence than in the anxiety-generating question of rational suicide in the elderly” (p. 217).On the one hand, a book that touches on the existential meaning of life, rational decision making, and the right to self-determination should have wide appeal to healers of all disciplines. On the other hand, I believe the book’s major appeal will be to clinicians from both the mental and general health arenas who work with older and chronically ill individuals and to teachers interested in educating our trainees to work more collaboratively and empathically with older adults, going above and beyond (or even eschewing) evidence-based practices in favor of listening and learning about the processes of living and dying.Dr. Lesser is Vice-Chair of the Department of Psychiatry and Biobehavioral Sciences, Geffen School of Medicine, UCLA, Chair of the Department of Psychiatry, Harbor-UCLA Medical Center, and is affiliated with the Los Angeles Biomedical Research Institute, Torrance, Calif.The author reports no financial relationships with commercial interests. FiguresReferencesCited byDetailsCited byNone Volume 174Issue 6 June 01, 2017Pages 600-601 Metrics KeywordsAdministrationOther Psychological IssuesSuicideGeriatricsPDF download History Accepted 1 March 2017 Published online 1 June 2017 Published in print 1 June 2017

Back to table of contents Previous article Next article IntrospectionFull AccessCompassion in the Eye of the BeholderIra Lesser, M.D.Ira LesserSearch for more papers by this author, M.D.Published Online:1 Oct 2016https://doi.org/10.1176/appi.ajp.2016.16060639AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail In June of 2016, a new California law (End of Life Option Act) relating to physician-assisted end of life issues took effect. This law, similar to laws in Oregon, Washington, and Vermont, authorizes “an adult who meets certain qualifications, and who has been determined by his or her attending physician to be suffering from a terminal disease, as defined, to make a request for a drug prescribed pursuant to these provisions for the purpose of ending his or her life” (1). Although the End of Life Option Act is silent on illnesses that are not deemed to be terminal, in other countries there is a trend for allowing physician-assisted suicide for intractable psychic pain (e.g., depression, bipolar disorder, borderline personality disorder). This has been written about, both in the popular media (2) and in the scientific literature (3–5). In thinking about these developments, I was reminded of a patient I treated over 30 years ago, and particularly, of one comment he made that remained etched in my mind all these years.Mr. A was a handsome, articulate man in his mid 30s who had a history of rapid-cycling bipolar disorder. We worked together intermittently over a period of 5 years, sometimes on a weekly basis, more often for medication management and dealing with crises. Mr. A was rarely euthymic; more often he was hypomanic or depressed. When hypomanic, he was charming, engaging, artistic, and a superb salesperson and entrepreneur who could do exceedingly well … until he became manic; then his charm turned to irritability and his entrepreneurship to gambling. He also spent much time depressed, having active suicidal ideation, but he had not made any suicide attempts. When depressed, he would be unemployed for sustained periods of time and, though never truly homeless, would have no consistent place of residence. He was estranged from his family and could not sustain any intimate relationships.One of the most important things he taught me about this terrible illness was its unpredictability. He mused, “How can I have a relationship when I go to sleep in a barren one-room apartment sleeping on a cot, having no money, being alone, and wishing I could die, then wake up feeling wonderful and thinking everything will work out? How crazy is this? And, if I can’t stand to live like this, why should anyone else choose to share it with me?” I have found sharing this insight of his to be a very useful empathic intervention with bipolar patients, who often resonate with it immediately.We tried the pharmacological interventions of the day, and when the depression was particularly intractable, he had two courses of ECT, which improved the depression but left him with significant memory impairment, about which he bitterly complained. Often he would scoff at the treatment I offered, and its (lack of) efficacy, but our rapport was such that he was mostly adherent with treatment recommendations.At one session, when he was quite depressed and voicing suicidal ideation, I said I wanted him to be hospitalized, voluntarily if he agreed or involuntarily if he did not. In response to this, he said to me, “Lesser, you would have more compassion for an injured dog lying in the street than you have for me.” I was stung by this comment, for surely he knew how much I cared about him. Did he not remember presenting me with the medallion he received for completing the Los Angeles Marathon and then asking that I keep it, thanking me for “enabling” him to run in it? He had often made caustic comments about me (how I dressed for example), but these were always said with a twinkle in his eye and did not feel like serious barbs. Being accused of having “no compassion” was a whole different matter.I did hospitalize him, and he did recover somewhat, but he continued to suffer greatly from his illness. Ultimately, he left treatment and moved away from the area where I practiced, and I had no further contact with him. About 5 years later, the physician who had performed the ECT gave me an obituary he had read about Mr. A. He had been found dead in a car, presumably a suicide.Most of us have had (and will have) patients who commit suicide, despite our best efforts. In this case, I was somewhat able to distance myself from the feelings associated with a suicide, for after all, he was “not my patient” any longer. Little comfort, though. After all these years, his comment about my lack of compassion still rings in my ears. Is hospitalizing someone against their will an act of “compassion” or is it, in their eyes, the very opposite? He survived the acute crisis precipitating this event and went on to live at least 5 years more. But, if those 5 years were primarily full of psychic pain for him, I can see how he would look at my actions as not being in his best interest.I wonder how the conversation with Mr. A might have gone if the End of Life Option Act, particularly the “European version,” was in place at the time. Having heard his and countless other stories and shared the pain patients experience as a result of their mental illness, do I believe that the patient’s “autonomy” should be the deciding factor? Do we ignore the fact that, for many patients, the acute psychic pain, managed empathically and contained, may recede? I am very uncomfortable with the movement to include mental disorders as a legitimate and “legal” reason to assist a patient to end his/her life, and I continue to believe in involuntary hospitalization when, in the clinician’s opinion, it is needed. Even this, a somewhat conservative position, can be challenged by those who believe that the “state” has no legal right to take away a person’s liberty, and there has long been a debate about the use (and utility) of involuntary hospitalization (5–7). Although there often is considerable angst when having to make these decisions, the literature suggests that close to 90% of those who survive a suicide attempt are alive decades later, and the majority of them are grateful that they did not die (8). I understand this intellectually, but having worked with Mr. A, I have a more visceral understanding of both sides of this issue and see more clearly that, when looking through our own prisms of perspective, we can reach such different conclusions. The challenge therapists face, what I faced, is how to remain fully engaged with the patient when such a fundamental disagreement is present.From the Department of Psychiatry, Harbor-UCLA Medical Center, and the Los Angeles Biomedical Research Institute, Department of Psychiatry and Biobehavioral Sciences, Geffen School of Medicine at UCLA, Los Angeles.Address correspondence to Dr. Lesser ([email protected]).References1 California State Senate: SB-128 End of life (date of implementation June 9, 2016) (https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201520160SB128)Google Scholar2 Aviv R: The death treatment: when should people with a non-terminal illness be helped to die? New Yorker, June 22, 2015Google Scholar3 Thienpont L, Verhofstadt M, Van Loon T, et al.: Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: a retrospective, descriptive study. BMJ Open 2015; 5:e007454Crossref, Medline, Google Scholar4 Kim SYH, De Vries RG, Peteet JR: Euthanasia and assisted suicide of patients with psychiatric disorders in the Netherlands 2011 to 2014. JAMA Psychiatry 2016; 73:362–368Crossref, Medline, Google Scholar5 Special Section: Suicide, Euthanasia, and Assisted Suicide: Past, Present, and Future. Int J Law Psychiatry 2013; 36(5–6):339–540Crossref, Medline, Google Scholar6 Bonn CE: Suicide and the state: the ethics of involuntary hospitalization for suicidal patients. Intersect: The Stanford Journal of Science, Technology and Society 2010; 3:40–49Google Scholar7 Testa M, West SG: Civil commitment in the United States. Psychiatry (Edgmont) 2010; 7:30–40Medline, Google Scholar8 Suominen K, Isometsä E, Suokas J, et al.: Completed suicide after a suicide attempt: a 37-year follow-up study. Am J Psychiatry 2004; 161:562–563Link, Google Scholar FiguresReferencesCited byDetailsCited byNone Volume 173Issue 10 October 01, 2016Pages 958-959 Metrics KeywordsMood Disorders-BipolarPsychotherapyAssisted SuicidePDF download History Published online 1 October 2016 Published in print 1 October 2016

Background. Non-adherence to antidepressant treatment is not routinely measured in practical clinical trials. It has not been related to outcomes in a large sample of adults with chronic and/or recurrent major depressive disorder (MDD) or any sample treated with antidepressant combinations. Methods. Adult outpatients with chronic and/or recurrent MDD were randomized to 12 weeks of treatment with bupropion-SR plus escitalopram, venlafaxine-XR plus mirtazapine, or escitalopram plus placebo. We compared non-adherence (the frequency with which daily medications were not taken) and specifically the frequency of temporarily stopping and/or skipping medication, or reducing or increasing the dose across treatments in 567 participants using a self-report questionnaire collected at each visit. We tested the association between non-adherence, and both treatment type and outcomes. Results. A non-adherence rate under 10% was reported by 77.9%, 70.9%, and 71.6% of participants during weeks 1-4, 5-12, and 1-12, respectively. Antidepressant combinations were associated with a higher non-adherence rate than monotherapy during weeks 1-4 and 1-12. During weeks 1-4, 24.1% stopped/skipped doses and 6.1% reduced the dose. During weeks 5-12, 34.7% stopped/skipped doses and 9.4% reduced the dose. Across 12 weeks, 43.2% stopped/skipped doses, and 12.9% reduced the dose. Stopping/skipping doses during all time frames and dose decreases during weeks 1-12 occurred most frequently with combination treatments. Non-adherence was unrelated to symptom remission, response, or symptom change. Conclusions. With closely monitored treatment, non-adherence is low and unrelated to depressive symptom outcome. Nonadherence is highest with antidepressant combinations. Specific non-adherent events are most often sporadic.

OBJECTIVE The authors sought to identify baseline clinical and sociodemographic characteristics associated with work productivity in depressed outpatients and to assess the effect of treatment on work productivity. METHOD Employed depressed outpatients 18-75 years old who completed the Work Productivity and Activity Impairment scale (N=1,928) were treated with citalopram (20-40 mg/day) in the Sequenced Treatment Alternatives to Relieve Depression study. For patients who did not remit after an initial adequate antidepressant trial (level 1), either a switch to sertraline, sustained-release bupropion, or extended-release venlafaxine or an augmentation with sustained-release bupropion or buspirone was provided (level 2). Participants' clinical and demographic characteristics and treatment outcomes were analyzed for associations with baseline work productivity and change in productivity over time. RESULTS Education, baseline depression severity, and melancholic, atypical, and recurrent depression subtypes were all independently associated with lower benefit to work productivity domains. During level 1 treatment, work productivity in several domains improved with reductions in depressive symptom severity. However, these findings did not hold true for level 2 outcomes; there was no significant association between treatment response and reduction in work impairment. Results were largely confirmed when multiple imputations were employed to address missing data. During this additional analysis, an association was also observed between greater impairment in work productivity and higher levels of anxious depression. CONCLUSIONS Patients with clinically significant reductions in symptom severity during initial treatment were more likely than nonresponders to experience significant improvements in work productivity. In contrast, patients who achieved symptom remission in second-step treatment continued to have impairment at work. Patients who have demonstrated some degree of treatment resistance are more prone to persistent impairment in occupational productivity, implying a need for additional, possibly novel, treatments.

AIMS:Ethnic differences in genotype frequency provide a natural condition for assessing the contribution of gene variations to the causes and treatments of disease. Accordingly, the purpose of this study was to determine whether ethnic variations in allele frequencies of the serotonin transporter gene-linked polymorphic region (5-HTTLPR) of the SLC6A4 gene were related to the response to the treatment of depression. MAIN METHODS:African-Americans (n=101) and Caucasians (n=100) with major depressive disorder were treated with the antidepressant citalopram (20-60mg/day) for 8weeks. Genotyping for the long (L) and short (s) alleles (LL, Ls, and ss) of the SLC6A4 gene was performed and the association between genotype and treatment response was assessed. KEY FINDINGS:Subjects in both ethnic groups showed a significant reduction in depression scores over time (p<.0001). However, in spite of a significantly greater frequency of the L allele in African-Americans as compared to Caucasians, a comparable clinical response between the two groups was found with 5-HTTLPR polymorphism not significantly associated with clinical response in either ethnic group. SIGNIFICANCE:The results are consistent with a previous finding and in accord with most of the results obtained in Caucasian subjects that SLC6A4 genotype is not related, at least by itself, to a response to treatment in either ethnic group to any clinically significant degree.

CONTEXT Rates of clinical diagnoses of schizophrenia in African American individuals appear to be elevated compared with other ethnic groups in the United States, contradicting population rates derived from epidemiologic surveys. OBJECTIVE To determine whether African American individuals would continue to exhibit significantly higher rates of clinical diagnoses of schizophrenia, even after controlling for age, sex, income, site, and education, as well as the presence or absence of serious affective disorder, as determined by experts blinded to race and ethnicity. A secondary objective was to determine if a similar pattern occurred in Latino subjects. DESIGN Ethnicity-blinded and -unblinded diagnostic assessments were obtained in 241 African American individuals (mean [SD] age, 34.3 [8.1] years; 57% women), 220 non-Latino white individuals (mean [SD] age, 32.7 [8.5] years; 53% women), and 149 Latino individuals (mean [SD] age, 33.5 [8.0] years; 58% women) at 6 US sites. Logistic regression models were used to determine whether elevated rates of schizophrenia in African American individuals would persist after controlling for various confounding variables including blinded expert consensus diagnoses of serious affective illness. SETTINGS Six academic medical centers across the United States. PARTICIPANTS Six hundred ten psychiatric inpatients and outpatients. MAIN OUTCOME MEASURE Relative odds of unblinded clinical diagnoses of schizophrenia in African American compared with white individuals. RESULTS A significant ethnicity/race effect (χ(2)(2)=10.4, P=.01) was obtained when schizophrenia was narrowly defined, controlling for all other predictors. The odds ratio comparing African American with non-Latino white individuals was significant (odds ratio=2.7; 95% CI, 1.5-5.1). Similar differences between African American and white individuals occurred when schizophrenia was more broadly defined (odds ratio=2.5; 95% CI, 1.4-4.5). African American individuals did not differ significantly from white individuals in overall severity of manic and depressive symptoms but did evidence more severe psychosis. CONCLUSIONS African American individuals exhibited significantly higher rates of clinical diagnoses of schizophrenia than non-Latino white subjects, even after controlling for covariates such as serious affective disorder.

OBJECTIVE Two antidepressant medication combinations were compared with selective serotonin reuptake inhibitor monotherapy to determine whether either combination produced a higher remission rate in first-step acute-phase (12 weeks) and long-term (7 months) treatment. METHOD The single-blind, prospective, randomized trial enrolled 665 outpatients at six primary and nine psychiatric care sites. Participants had at least moderately severe nonpsychotic chronic and/or recurrent major depressive disorder. Escitalopram (up to 20 mg/day) plus placebo, sustained-release bupropion (up to 400 mg/day) plus escitalopram (up to 20 mg/day), or extended-release venlafaxine (up to 300 mg/day) plus mirtazapine (up to 45 mg/day) was delivered (1:1:1 ratio) by using measurement-based care. The primary outcome was remission, defined as ratings of less than 8 and less than 6 on the last two consecutive applications of the 16-item Quick Inventory of Depressive Symptomatology--Self-Report. Secondary outcomes included side effect burden, adverse events, quality of life, functioning, and attrition. RESULTS Remission and response rates and most secondary outcomes were not different among treatment groups at 12 weeks. The remission rates were 38.8% for escitalopram-placebo, 38.9% for bupropion-escitalopram, and 37.7% for venlafaxine-mirtazapine, and the response rates were 51.6%-52.4%. The mean number of worsening adverse events was higher for venlafaxine-mirtazapine (5.7) than for escitalopram-placebo (4.7). At 7 months, remission rates (41.8%-46.6%), response rates (57.4%-59.4%), and most secondary outcomes were not significantly different. CONCLUSIONS Neither medication combination outperformed monotherapy. The combination of extended-release venlafaxine plus mirtazapine may have a greater risk of adverse events.

OBJECTIVE:The investigators examined whether outcomes differ by race-ethnicity for patients with major depressive disorder in acute- (12 weeks) and continuation-phase (weeks 12-28) treatment with one of two antidepressant combinations or one selective serotonin reuptake inhibitor.METHODS:This single-blind, seven-month prospective, randomized trial enrolled 352 non-Hispanic white (59%), 169 black (28%), and 79 white Hispanic (13%) participants from six primary and nine psychiatric care U.S. sites. Patients had nonpsychotic chronic or recurrent major depressive disorder (or both) of at least moderate severity. Escitalopram plus placebo, bupropion sustained-release plus escitalopram, or venlafaxine extended-release plus mirtazapine were delivered according to measurement-based care. The primary outcome was remission (last two consecutive 16-item Quick Inventory of Depressive Symptomatology-Self-Report ratings <8 and <6); secondary outcomes included side effects, adverse events, quality of life, function, and attrition.RESULTS:Black participants had greater baseline psychiatric and medical comorbidity. Baseline depression severity did not significantly differ between groups. In both phases more blacks than those in other groups exited the trial early. There were only minor differences in side effects, no significant differences in remission rates, and no significant differences between groups in other outcomes for each treatment.CONCLUSIONS:Despite differences in sociodemographic characteristics and comorbidities, when measurement-based care was used, members of different minority groups had similar outcomes when treated with one antidepressant or a combination of two antidepressants. Black participants had the highest attrition rate, an important issue to address in clinical care.

Background: The clinical effects of antidepressant combinations vs. monotherapy as initial treatment for major depression with melancholic features (MDD-MF) are unknown.Methods: Outpatients with chronic or recurrent major depression (MDD) were randomized to initial treatment with escitalopram + placebo (the MONO condition), bupropion-sustained release + escitalopram, or venlafaxine-extended release + mirtazapine (the COMB conditions) in the Combining Medications to Enhance Depression Outcomes (CO-MED) trial. Secondary data analyses were conducted to compare demographic and clinical characteristics, and contrast clinical responses according to drug treatment, in patients with MDD-MF (n = 124) and non-melancholic MDD (n =481).Results: While numerically lower, remission rates in MDD-MF did not differ significantly from those with non-melancholic MDD either at 12 (33.1% vs. 41.0%, aOR 1.16, p = 0.58) or 28 (39.5% vs. 46.8%, aOR = 1.02, p= 0.93) weeks of treatment. Remission rates did not differ significantly between combination and monotherapy groups in either MDD-MF or non-melancholic MDD patients at either time point. Similar conclusions were reached for response rates, premature study discontinuation, and self-rated depression symptom severity.Limitations: This is a secondary analysis of data from the CO-MED trial, which was not designed to address differential treatment response in melancholic and non-melancholic MDD.Conclusions: We found no evidence of differential remission or response rates to antidepressant combination or monotherapy between melancholic/non-melancholic MDD patients, or according to antidepressant treatment group, after 12 and 28 weeks. Melancholic features may not be a valid predictor of more favorable response to antidepressant combination therapy as initial treatment. (C) 2011 Elsevier B.V. All rights reserved.

OBJECTIVE To explore relationships between baseline sociodemographic and clinical features and baseline suicidal ideation, and treatment effects on suicidal ideation and behavior, in depressed outpatients. METHOD From March 2008 to September 2009, the Combining Medications to Enhance Depression Outcomes study, a single-blind, 7-month randomized trial, enrolled outpatients with nonpsychotic chronic and/or recurrent major depressive disorder (DSM-IV-TR criteria) in primary and psychiatric care (N = 665). Participants received escitalopram plus placebo, bupropion sustained release (SR) plus escitalopram, or venlafaxine extended release (XR) plus mirtazapine. The primary outcome measure for this report is presence of suicidal ideation assessed by the Concise Health Risk Tracking Self-Report, which measures suicidal ideation and behaviors over the last 24 hours. Sociodemographic and clinical features were compared in those with versus without baseline ideation. At 4, 12, and 28 weeks, treatment effects on suicidality were assessed, and unadjusted and adjusted outcomes were compared among those with and without baseline ideation using linear, logistic, ordinal logistic, and negative binomial regression models. RESULTS Baseline suicidal ideation was associated with greater depressive severity, childhood neglect, childhood abuse, early major depressive disorder onset, greater psychiatric comorbidity, and worse functioning and quality of life. After adjustment for treatment, gender, age at first depressive episode, obsessive-compulsive symptoms, and depressive severity, depressive symptom outcomes did not differ between ideation groups at 12 or 28 weeks or between treatments. Overall, 79% of participants with baseline suicidal ideation had none at week 4, 83% had none at week 12, and 86% had none at week 28. All treatments reduced ideation, with bupropion-SR plus escitalopram the most effective at week 12 (P < .01). In participants without baseline ideation, emergent ideation did not differ between treatments: 2.5% had ideation at 4 weeks, 1.3% had ideation at 12 weeks, and only 1.7% had ideation at 28 weeks. Four patients (all receiving venlafaxine-XR plus mirtazapine) attempted suicide (P = .0162). CONCLUSION Baseline ideation did not affect depressive symptom outcome. Bupropion-SR plus escitalopram most effectively reduced ideation. Ideation emergence was uncommon. Venlafaxine-XR plus mirtazapine may pose a higher risk of suicide attempts. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00590863.

The purpose of this study was to investigate the relationships of chronic stress, social undermining, and social support with symptom reduction and remission in depressed patients treated with antidepressant medication (citalopram), and to determine whether these relationships were moderated by ethnicity. A sample of 301 treatment-seeking adult patients with non-psychotic depression, including 169 African American and 132 Caucasian men and women, were enrolled in an eight week, dose-escalation clinical trial. Intent-to-treat analyses indicated that, consistent with expectations, more baseline social support was associated with greater symptom reduction and higher likelihood of remission, especially at higher levels of social undermining. Additionally, increases in social support from baseline to last visit were associated with more symptom reduction and higher likelihood of remission. However, contrary to expectations, higher levels of baseline social undermining were associated with more symptom reduction in Caucasians, but not in African Americans. Results supported the treatment-enhancing effect of available social support at the beginning of treatment and over the course of treatment. Efforts to enhance social support for patients on antidepressants should be considered as part of comprehensive treatment.

The present study examined the relationship between religiosity/spirituality and treatment response to antidepressant medication (citalopram). One-hundred and forty-eight Caucasian and African-American adults with uncomplicated major depression were treated with citalopram (20-60 mg/day) over an eight-week period in a prospective multi-site clinical trial. Treatment response was assessed weekly with the Hamilton Rating Scale for Depression. Religiosity (i.e., religious behaviours) and spirituality (i.e., spiritual well-being) were assessed at week 3. No significant associations between spirituality and treatment response were found; however, there was a strong curvilinear relationship between religiosity and treatment response. Compared to lower or higher levels of religiosity, a moderate level of religiosity was significantly associated with a higher likelihood of remission and greater reduction in severity of depression. This association was independent of social support, ethnicity, gender, education, and baseline depression severity. A moderate amount of religiosity appears to be independently associated with an enhanced treatment response to citalopram.

In the case of large-scale epidemiological studies, there is evidence of substantial disagreement when lay diagnoses of schizophrenia based on structured interviews are compared with expert diagnoses of the same patients. Reasons for this level of disagreement are investigated in the current study, which made use of advances in text-mining techniques and associated structural representations of language expressions. Specifically, the current study examined whether content analyses of transcribed diagnostic interviews obtained from 150 persons with serious psychiatric disorders yielded any discernable patterns that correlated with diagnostic inconsistencies of schizophrenia. In summary, it was found that the patterning or structure of spontaneous self-reports of emotion states in the diagnostic interview was associated with diagnostic inconsistencies of schizophrenia, irrespective of confounders; i.e., age of patient, gender, or ethnicity. In particular, complex emotion patterns were associated with greater disagreement between experts and trained lay interviewers than were simpler patterns.