OBJETIVO: Realizar um breve percurso sobre o desenvolvimento conceitual de um dos construtos psicológicos de maior evidência nos dias atuais, a saber: o transtorno de personalidade antissocial (TPAS). Especificamente, esse percurso se realiza no sistema categórico proposto pela Associação Americana de Psiquiatria (APA), o Manual Diagnóstico e Estatístico de Distúrbios Mentais (DSM). MÉTODO: Utilizou-se a revisão literária sobre a evolução e a avaliação do construto associada a pesquisas empíricas consultadas nos principais livros e periódicos de reconhecimento internacional na área, tais como: Personality and Individual Differences, Psychological Medicine, Annual Review of Clinical Psychology, Psychological Bulletin, Journal of Abnormal Psychology, Journal of Personality Assessment, International Journal of Offender Therapy and Comparative Criminology, Aggression and Violent Behavior, Handbook of Psychopathy, entre outros. RESULTADO: Observa-se que o diagnóstico do TPAS é baseado nos critérios categóricos e não dimensionais. Isso significa que o sistema não consegue predizer a priori a variabilidade (intensidade) dos traços desse transtorno por ser o DSM desenvolvido no reconhecimento de sintomas e síndromes. CONCLUSÃO: Apesar de o TPAS ter passado por diversas revisões e de apresentar insuficiência taxonômica, ele ainda é amplamente utilizado no diagnóstico e no prognóstico clínico de condições relacionadas ao comportamento social desviante.OBJECTIVE: This present work does a brief developmental route about one of the most evidence contemporary construct: the antisocial personality disorder (APD). Specifically, this guide is realized in accordance to categorical system raised by American Psychiatry Association (APA), the Diagnosis Statistical of Mental Disorders (DSM). METHOD: This article uses a literature revision about the evolution and assessment of the construct associate to empirical studies counseled in main books and journals worldwide recognized in the area as: Personality and Individual Differences, Psychological Medicine, Annual Review of Clinical Psychology, Psychological Bulletin, Journal of Abnormal Psychology, Journal of Personality Assessment, International Journal of Offender Therapy and Comparative Criminology, Aggression and Violent Behavior, Handbook of Psychopathy, among others. RESULT: It observes that diagnosis of APD is based in categorical criteria not dimensionally. It means that system doesn't predict to prior the traits variability (intensity) of that disorder because the DSM it was development to recognize symptoms and syndromes. CONCLUSION: Despite the APD has gone for different revisions and still presents taxonomic deficient it remains widely used in clinical diagnoses and prognoses related to social deviant behavior.
OBJETIVO: Realizar um breve percurso sobre o desenvolvimento conceitual de um dos construtos psicológicos de maior evidência nos dias atuais, a saber: o transtorno de personalidade antissocial (TPAS). Especificamente, esse percurso se realiza no sistema categórico proposto pela Associação Americana de Psiquiatria (APA), o Manual Diagnóstico e Estatístico de Distúrbios Mentais (DSM). MÉTODO: Utilizou-se a revisão literária sobre a evolução e a avaliação do construto associada a pesquisas empíricas consultadas nos principais livros e periódicos de reconhecimento internacional na área, tais como: Personality and Individual Differences, Psychological Medicine, Annual Review of Clinical Psychology, Psychological Bulletin, Journal of Abnormal Psychology, Journal of Personality Assessment, International Journal of Offender Therapy and Comparative Criminology, Aggression and Violent Behavior, Handbook of Psychopathy, entre outros. RESULTADO: Observa-se que o diagnóstico do TPAS é baseado nos critérios categóricos e não dimensionais. Isso significa que o sistema não consegue predizer a priori a variabilidade (intensidade) dos traços desse transtorno por ser o DSM desenvolvido no reconhecimento de sintomas e síndromes. CONCLUSÃO: Apesar de o TPAS ter passado por diversas revisões e de apresentar insuficiência taxonômica, ele ainda é amplamente utilizado no diagnóstico e no prognóstico clínico de condições relacionadas ao comportamento social desviante.OBJECTIVE: This present work does a brief developmental route about one of the most evidence contemporary construct: the antisocial personality disorder (APD). Specifically, this guide is realized in accordance to categorical system raised by American Psychiatry Association (APA), the Diagnosis Statistical of Mental Disorders (DSM). METHOD: This article uses a literature revision about the evolution and assessment of the construct associate to empirical studies counseled in main books and journals worldwide recognized in the area as: Personality and Individual Differences, Psychological Medicine, Annual Review of Clinical Psychology, Psychological Bulletin, Journal of Abnormal Psychology, Journal of Personality Assessment, International Journal of Offender Therapy and Comparative Criminology, Aggression and Violent Behavior, Handbook of Psychopathy, among others. RESULT: It observes that diagnosis of APD is based in categorical criteria not dimensionally. It means that system doesn't predict to prior the traits variability (intensity) of that disorder because the DSM it was development to recognize symptoms and syndromes. CONCLUSION: Despite the APD has gone for different revisions and still presents taxonomic deficient it remains widely used in clinical diagnoses and prognoses related to social deviant behavior.
OBJETIVO: Realizar um breve percurso sobre o desenvolvimento conceitual de um dos construtos psicológicos de maior evidência nos dias atuais, a saber: o transtorno de personalidade antissocial (TPAS). Especificamente, esse percurso se realiza no sistema categórico proposto pela Associação Americana de Psiquiatria (APA), o Manual Diagnóstico e Estatístico de Distúrbios Mentais (DSM). MÉTODO: Utilizou-se a revisão literária sobre a evolução e a avaliação do construto associada a pesquisas empíricas consultadas nos principais livros e periódicos de reconhecimento internacional na área, tais como: Personality and Individual Differences, Psychological Medicine, Annual Review of Clinical Psychology, Psychological Bulletin, Journal of Abnormal Psychology, Journal of Personality Assessment, International Journal of Offender Therapy and Comparative Criminology, Aggression and Violent Behavior, Handbook of Psychopathy, entre outros. RESULTADO: Observa-se que o diagnóstico do TPAS é baseado nos critérios categóricos e não dimensionais. Isso significa que o sistema não consegue predizer a priori a variabilidade (intensidade) dos traços desse transtorno por ser o DSM desenvolvido no reconhecimento de sintomas e síndromes. CONCLUSÃO: Apesar de o TPAS ter passado por diversas revisões e de apresentar insuficiência taxonômica, ele ainda é amplamente utilizado no diagnóstico e no prognóstico clínico de condições relacionadas ao comportamento social desviante.OBJECTIVE: This present work does a brief developmental route about one of the most evidence contemporary construct: the antisocial personality disorder (APD). Specifically, this guide is realized in accordance to categorical system raised by American Psychiatry Association (APA), the Diagnosis Statistical of Mental Disorders (DSM). METHOD: This article uses a literature revision about the evolution and assessment of the construct associate to empirical studies counseled in main books and journals worldwide recognized in the area as: Personality and Individual Differences, Psychological Medicine, Annual Review of Clinical Psychology, Psychological Bulletin, Journal of Abnormal Psychology, Journal of Personality Assessment, International Journal of Offender Therapy and Comparative Criminology, Aggression and Violent Behavior, Handbook of Psychopathy, among others. RESULT: It observes that diagnosis of APD is based in categorical criteria not dimensionally. It means that system doesn't predict to prior the traits variability (intensity) of that disorder because the DSM it was development to recognize symptoms and syndromes. CONCLUSION: Despite the APD has gone for different revisions and still presents taxonomic deficient it remains widely used in clinical diagnoses and prognoses related to social deviant behavior.
OBJETIVO: Esta revisão da literatura tem como objetivo verificar a prevalência e os fatores de risco do parto traumático e do transtorno de estresse pós-traumático (TEPT) relacionado com o parto. MÉTODOS: Foi realizada uma pesquisa nos bancos de dados PubMed e BIREME, com as expressões "traumatic birth", "traumatic delivery", "postpartum posttraumatic stress disorder", "childbirth", "stress disorder" e avaliados estudos de 1994 a 2009. RESULTADOS: Três estudos qualitativos e quatro quantitativos sobre o parto traumático mostram que sua prevalência varia de 21,4% a 34% e que a mulher apresenta, durante o trabalho de parto ou o parto, medo intenso de sua morte ou do bebê, além de impotência, desamparo e horror. O parto traumático está relacionado a partos dolorosos, com procedimentos obstétricos de urgência e com assistência inadequada da equipe de saúde. Quanto ao TEPT relacionado com o parto, foram encontrados um estudo qualitativo e doze quantitativos e sua prevalência variou de 1,3% a 5,9%. Mulheres que apresentaram sintomas dissociativos ou emoções negativas no parto, que tiveram eventos traumáticos prévios, depressão na gestação e que tiveram pouco suporte social e pouco apoio da equipe de saúde são as mais vulneráveis para TEPT pós-parto. CONCLUSÃO: O parto traumático, apesar de pouco conhecido, não é um evento raro e traz consequências negativas para a vida da mulher, podendo inclusive ser sucedido de TEPT. A equipe de saúde que assiste mulheres no periparto deve estar preparada para prevenir e identificar esses casos.OBJECTIVE: The objective of this review was to examine the prevalence and risk factors of traumatic birth and childbirth-related posttraumatic stress disorder. METHODS: A literature search was carried out on the PubMed and BIREME databases using the search strings "traumatic birth", "traumatic delivery", "postpartum posttraumatic stress disorder", "childbirth" and "stress disorder". The search encompassed articles on prevalence and risk factors of traumatic delivery and childbirth-related posttraumatic stress disorder published between 1994 and 2009. RESULTS: Three qualitative and four quantitative studies on traumatic delivery revealed a rate ranging from 21.4% to 34%. Traumatic delivery is defined when, during labor or delivery, the mother presents intense fear of her own death or that of her child, besides feelings of impotence, helplessness and horror. Traumatic deliver is associated with painful delivery, emergency obstetric procedures and inadequate care from the health team. With regard to post partum PTSD, one qualitative and twelve quantitative studies were found, reporting a prevalence of 1.3% to 5.9%. Women who presented dissociation symptoms or negative emotions during delivery, or a history of traumatic events, depression in pregnacy, poor social support and a perception of a staff less suportive proved more vulnerable to post partum PTSD. CONCLUSION: Although not well understood, traumatic delivery a relatively common event which negatively impacts women's lives and may be a precursor to post partum PTSD. Health teams charged with caring for women during the peripartum period should be aware of this condition to allow identification and prevention of cases.
INTRODUÇÃO: Estudo realizado em clínicas cirúrgicas de dois hospitais de Belo Horizonte com 100 pacientes adultos de ambos os sexos, distribuídos em dois grupos: Grupo 1 - 22 pacientes sem experiência com cirurgia; Grupo 2 - 78 pacientes submetidos previamente a outras operações de médio e grande porte. OBJETIVO: Avaliar o impacto do estresse psíquico em pacientes submetidos a operações de grande porte sob anestesia geral, relacionando suas reações físicas e psíquicas com as diferentes fases do estresse. MÉTODO: Para investigação do estresse, utilizou-se o Inventário de Sintomas de Stress para Adultos, desenvolvido por Lipp, um dia antes e dois dias e sete dias após a operação. A comparação dos grupos quanto às variáveis "sexo", "dor" e "percentual de estresse" foi realizada pelo teste do qui ao quadrado e para a variável idade foi utilizado o teste t de Student. As diferenças foram consideradas significativas para p < 0,05. RESULTADOS: Os grupos não foram homogêneos quanto ao percentual geral de estresse nas três mensurações. O Grupo 1 diminuiu e o Grupo 2 aumentou o estresse no pós-operatório. Prevaleceram sintomas psíquicos do estresse em ambos os grupos. CONCLUSÃO: O fato de ter sido operado previamente reduziu a tensão pré-operatória, porém não interferiu nos distúrbios emocionais pós-operatórios.INTRODUCTION: One hundred adult patients hospitalized in the surgical wards of two hospitals of Belo Horizonte city, Brazil, were separated into two groups: group 1, 22 patients who had no previous experience with surgeries; and group 2, 78 patients who had been previously submitted to major surgical procedures. OBJECTIVE: To evaluate the impact of psychical stress on patients submitted to major operations under general anesthesia and to correlate physical and psychological reactions to different stages of stress. METHOD: The Stress Symptoms Inventory for Adults was used one day before and two and seven days after the operation. The groups were compared with regard to sex, level of pain and stress percentage with the chi-square test and for age with the Student t test. The level of significance was set at p < 0.05. RESULTS: The groups were not homogeneous regarding the general percentage of stress on the occasion of the three measurements. The level of stress was decreased in Group 1 and increased in Group 2. Psychic stress symptoms prevailed in both groups. CONCLUSION: Previous experience with surgery under general anesthesia reduces preoperative stress, but does not affect postoperative stress.
Context Overlapping neurobiological pathways between obesity and addiction disorders are currently in discussion. Whereas the hypothalamic regulation of energy homeostasis by endocrine feedback signals has been widely investigated, its interplay with mesolimbic reward-associated pathways represents a rich field of future research.
Objective To assess changes in regional brain activation in response to food-related cues in association with body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) and the plasma concentration of the appetite-regulating peptide leptin.
Design Case-control study.
Setting Academic addiction and brain imaging center, Central Institute of Mental Health, Mannheim, Germany.
Participants Twenty-one obese subjects (BMI >30) and 23 age- and sex-matched nonobese control subjects (BMI 18.5-24.0) recruited by advertisements.
Main Outcome Measures Regional brain activation (blood oxygen level–dependent response) in response to visual cue presentation and association of the brain activation with BMI and plasma leptin concentration.
Results Significant positive relationships were observed for food cue–induced brain activations in the ventral striatum in association with the plasma concentration of leptin (r = 0.27; P = .04) and with BMI (r = 0.47; P = .001).
Conclusions Data suggest a physiological role of satiety factors in modulating the responsivity of mesolimbic circuits to food cues. Moreover, an altered homeostatic feedback regulation of reward pathways might explain addictionlike behavior and the inability of obese patients to adapt food intake to physiological needs.
Context There was a paucity of comparative pharmacological research for initial treatment of bipolar I disorder, manic or mixed phase, in children and adolescents.
Objective To investigate which medication to administer first to antimanic medication–naive subjects.
Design, Setting, and Participants The Treatment of Early Age Mania (TEAM) study recruited 6- to 15-year-old children and adolescents with DSM-IV bipolar I disorder (manic or mixed phase) at 5 US sites from 2003 to 2008 into a controlled, randomized, no-patient-choice, 8-week protocol. Blinded, independent evaluators conducted all baseline and end-point assessments.
Interventions Subjects received a titrated schedule of lithium, divalproex sodium, or risperidone. Medications were increased weekly only if there was inadequate response, and no dose-limiting adverse effects, to maximum doses of lithium carbonate (1.1-1.3 mEq/L), divalproex sodium (111-125 μg/mL), and risperidone (4-6 mg).
Main Outcome Measures Primary outcome measures were the Clinical Global Impressions for Bipolar Illness Improvement–Mania and the Modified Side Effects Form for Children and Adolescents.
Results There were 279 antimanic medication–naive subjects (mean [SD] age, 10.1 [2.8] years; 50.2% female) who had the following characteristics: 100% elated mood and/or grandiosity, 77.1% psychosis, 97.5% mixed mania, 99.3% daily rapid cycling, and mean (SD) mania duration of 4.9 (2.5) years. The mean (SD) titrated lithium level was 1.09 (0.34) mEq/L, and the mean (SD) divalproex sodium level was 113.6 (23.0) μg/mL. The mean (SD) titrated risperidone dose was 2.57 (1.21) mg. Higher response rates occurred with risperidone vs lithium (68.5% vs 35.6%; 21 = 16.9, P < .001) and vs divalproex sodium (68.5% vs 24.0%; 21 = 28.3, P < .001). Response to lithium vs divalproex sodium did not differ. The discontinuation rate was higher for lithium than for risperidone (21 = 6.4, P = .011). Increased weight gain, body mass index, and prolactin level occurred with risperidone vs lithium (F1,212 = 45.5, P < .001; F1,212 = 39.1, P < .001; and F1,213 = 191.4, P < .001, respectively) and vs divalproex sodium (F1,212 = 34.7, P < .001; F1,212 = 45.3, P < .001; and F1,213 = 209.4, P < .001, respectively). The thyrotropin level increased in subjects taking lithium (t62 = 11.3, P < .001).
Conclusions Risperidone was more efficacious than lithium or divalproex sodium for the initial treatment of childhood mania but had potentially serious metabolic effects.
Context Patients with depression and poorly controlled diabetes mellitus, coronary heart disease (CHD), or both have higher medical complication rates and higher health care costs, suggesting that more effective care management of psychiatric and medical disease control might also reduce medical service use and enhance quality of life.
Objective To evaluate the cost-effectiveness of a multicondition collaborative treatment program (TEAMcare) compared with usual primary care (UC) in outpatients with depression and poorly controlled diabetes or CHD.
Design Randomized controlled trial of a systematic care management program aimed at improving depression scores and hemoglobin A1c (HbA1c), systolic blood pressure (SBP), and low-density lipoprotein cholesterol (LDL-C) levels.
Setting Fourteen primary care clinics of an integrated health care system.
Patients Population-based screening identified 214 adults with depressive disorder and poorly controlled diabetes or CHD.
Intervention Physician-supervised nurses collaborated with primary care physicians to provide treatment of multiple disease risk factors.
Main Outcome Measures Blinded assessments evaluated depressive symptoms, SBP, and HbA1c at baseline and at 6, 12, 18, and 24 months. Fasting LDL-C concentration was assessed at baseline and at 12 and 24 months. Health plan accounting records were used to assess medical service costs. Quality-adjusted life-years (QALYs) were assessed using a previously developed regression model based on intervention vs UC differences in HbA1c, LDL-C, and SBP levels over 24 months.
Results Over 24 months, compared with UC controls, intervention patients had a mean of 114 (95% CI, 79 to 149) additional depression-free days and an estimated 0.335 (95% CI, –0.18 to 0.85) additional QALYs. Intervention patients also had lower mean outpatient health costs of $594 per patient (95% CI, –$3241 to $2053) relative to UC patients.
Conclusions For adults with depression and poorly controlled diabetes, CHD, or both, a systematic intervention program aimed at improving depression scores and HbA1c, SBP, and LDL-C levels seemed to be a high-value program that for no or modest additional cost markedly improved QALYs.
Context Purpose in life is associated with a substantially reduced risk of Alzheimer disease (AD), but the neurobiologic basis of this protective effect remains unknown.
Objective To test the hypothesis that purpose in life reduces the deleterious effects of AD pathologic changes on cognition in advanced age.
Design A longitudinal, epidemiologic, clinicopathologic study of aging was conducted that included detailed annual clinical evaluations and brain autopsy.
Participants Two hundred forty-six community-based older persons from the Rush Memory and Aging Project participated.
Main Outcome Measures Purpose in life was assessed via structured interview, and cognitive function was evaluated annually and proximate to death. On postmortem examination, 3 indexes of AD pathologic features were quantified: global AD pathologic changes, amyloid, and tangles. The associations of disease pathologic changes and purpose in life with cognition were examined using linear regression and mixed models.
Results Purpose in life modified the association between the global measure of AD pathologic changes and cognition (mean [SE] parameter estimate, 0.532 [0.211]; P = .01), such that participants who reported higher levels of purpose in life exhibited better cognitive function despite the burden of the disease. Purpose in life also reduced the association of tangles with cognition (parameter estimate, 0.042 [0.019]; P = .03), and the protective effect of purpose in life persisted even after controlling for several potentially confounding variables. Furthermore, in analyses examining whether purpose in life modified the association between AD pathologic effects and the rate of cognitive decline, we found that higher levels of purpose in life reduced the effect of AD pathologic changes on cognitive decline (parameter estimate, 0.085 [0.039]; P = .03).
Conclusion Higher levels of purpose in life reduce the deleterious effects of AD pathologic changes on cognition in advanced age.
Context Depression and dementia are common in older adults and often co-occur, but it is unclear whether depression is an etiologic risk factor for dementia.
Objective To clarify the timing and nature of the association between depression and dementia.
Design We examined depressive symptoms assessed in midlife (1964-1973) and late life (1994-2000) and the risks of dementia, Alzheimer disease (AD), and vascular dementia (VaD) (2003-2009) in a retrospective cohort study. Depressive symptoms were categorized as none, midlife only, late life only, or both. Cox proportional hazards models (age as timescale) adjusted for demographics and medical comorbidities were used to examine depressive symptom category and risk of dementia, AD, or VaD.
Setting Kaiser Permanente Medical Care Program of Northern California.
Participants Thirteen thousand five hundred thirty-five long-term Kaiser Permanente members.
Main Outcome Measure Any medical record diagnosis of dementia or neurology clinic diagnosis of AD or VaD.
Results Subjects had a mean (SD) age of 81.1 (4.5) years in 2003, 57.9% were women, and 24.2% were nonwhite. Depressive symptoms were present in 14.1% of subjects in midlife only, 9.2% in late life only, and 4.2% in both. During 6 years of follow-up, 22.5% were diagnosed with dementia (5.5% with AD and 2.3% with VaD). The adjusted hazard of dementia was increased by approximately 20% for midlife depressive symptoms only (hazard ratio, 1.19 [95% CI, 1.07-1.32]), 70% for late-life symptoms only (1.72 [1.54-1.92]), and 80% for both (1.77 [1.52-2.06]). When we examined AD and VaD separately, subjects with late-life depressive symptoms only had a 2-fold increase in AD risk (hazard ratio, 2.06 [95% CI, 1.67-2.55]), whereas subjects with midlife and late-life symptoms had more than a 3-fold increase in VaD risk (3.51 [2.44-5.05]).
Conclusions Depressive symptoms in midlife or in late life are associated with an increased risk of developing dementia. Depression that begins in late life may be part of the AD prodrome, while recurrent depression may be etiologically associated with increased risk of VaD.
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Context Overlapping neurobiological pathways between obesity and addiction disorders are currently in discussion. Whereas the hypothalamic regulation of energy homeostasis by endocrine feedback signals has been widely investigated, its interplay with mesolimbic reward-associated pathways represents a rich field of future research.
Objective To assess changes in regional brain activation in response to food-related cues in association with body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) and the plasma concentration of the appetite-regulating peptide leptin.
Design Case-control study.
Setting Academic addiction and brain imaging center, Central Institute of Mental Health, Mannheim, Germany.
Participants Twenty-one obese subjects (BMI >30) and 23 age- and sex-matched nonobese control subjects (BMI 18.5-24.0) recruited by advertisements.
Main Outcome Measures Regional brain activation (blood oxygen level–dependent response) in response to visual cue presentation and association of the brain activation with BMI and plasma leptin concentration.
Results Significant positive relationships were observed for food cue–induced brain activations in the ventral striatum in association with the plasma concentration of leptin (r = 0.27; P = .04) and with BMI (r = 0.47; P = .001).
Conclusions Data suggest a physiological role of satiety factors in modulating the responsivity of mesolimbic circuits to food cues. Moreover, an altered homeostatic feedback regulation of reward pathways might explain addictionlike behavior and the inability of obese patients to adapt food intake to physiological needs.
Context There was a paucity of comparative pharmacological research for initial treatment of bipolar I disorder, manic or mixed phase, in children and adolescents.
Objective To investigate which medication to administer first to antimanic medication–naive subjects.
Design, Setting, and Participants The Treatment of Early Age Mania (TEAM) study recruited 6- to 15-year-old children and adolescents with DSM-IV bipolar I disorder (manic or mixed phase) at 5 US sites from 2003 to 2008 into a controlled, randomized, no-patient-choice, 8-week protocol. Blinded, independent evaluators conducted all baseline and end-point assessments.
Interventions Subjects received a titrated schedule of lithium, divalproex sodium, or risperidone. Medications were increased weekly only if there was inadequate response, and no dose-limiting adverse effects, to maximum doses of lithium carbonate (1.1-1.3 mEq/L), divalproex sodium (111-125 μg/mL), and risperidone (4-6 mg).
Main Outcome Measures Primary outcome measures were the Clinical Global Impressions for Bipolar Illness Improvement–Mania and the Modified Side Effects Form for Children and Adolescents.
Results There were 279 antimanic medication–naive subjects (mean [SD] age, 10.1 [2.8] years; 50.2% female) who had the following characteristics: 100% elated mood and/or grandiosity, 77.1% psychosis, 97.5% mixed mania, 99.3% daily rapid cycling, and mean (SD) mania duration of 4.9 (2.5) years. The mean (SD) titrated lithium level was 1.09 (0.34) mEq/L, and the mean (SD) divalproex sodium level was 113.6 (23.0) μg/mL. The mean (SD) titrated risperidone dose was 2.57 (1.21) mg. Higher response rates occurred with risperidone vs lithium (68.5% vs 35.6%; 21 = 16.9, P < .001) and vs divalproex sodium (68.5% vs 24.0%; 21 = 28.3, P < .001). Response to lithium vs divalproex sodium did not differ. The discontinuation rate was higher for lithium than for risperidone (21 = 6.4, P = .011). Increased weight gain, body mass index, and prolactin level occurred with risperidone vs lithium (F1,212 = 45.5, P < .001; F1,212 = 39.1, P < .001; and F1,213 = 191.4, P < .001, respectively) and vs divalproex sodium (F1,212 = 34.7, P < .001; F1,212 = 45.3, P < .001; and F1,213 = 209.4, P < .001, respectively). The thyrotropin level increased in subjects taking lithium (t62 = 11.3, P < .001).
Conclusions Risperidone was more efficacious than lithium or divalproex sodium for the initial treatment of childhood mania but had potentially serious metabolic effects.
Context Patients with depression and poorly controlled diabetes mellitus, coronary heart disease (CHD), or both have higher medical complication rates and higher health care costs, suggesting that more effective care management of psychiatric and medical disease control might also reduce medical service use and enhance quality of life.
Objective To evaluate the cost-effectiveness of a multicondition collaborative treatment program (TEAMcare) compared with usual primary care (UC) in outpatients with depression and poorly controlled diabetes or CHD.
Design Randomized controlled trial of a systematic care management program aimed at improving depression scores and hemoglobin A1c (HbA1c), systolic blood pressure (SBP), and low-density lipoprotein cholesterol (LDL-C) levels.
Setting Fourteen primary care clinics of an integrated health care system.
Patients Population-based screening identified 214 adults with depressive disorder and poorly controlled diabetes or CHD.
Intervention Physician-supervised nurses collaborated with primary care physicians to provide treatment of multiple disease risk factors.
Main Outcome Measures Blinded assessments evaluated depressive symptoms, SBP, and HbA1c at baseline and at 6, 12, 18, and 24 months. Fasting LDL-C concentration was assessed at baseline and at 12 and 24 months. Health plan accounting records were used to assess medical service costs. Quality-adjusted life-years (QALYs) were assessed using a previously developed regression model based on intervention vs UC differences in HbA1c, LDL-C, and SBP levels over 24 months.
Results Over 24 months, compared with UC controls, intervention patients had a mean of 114 (95% CI, 79 to 149) additional depression-free days and an estimated 0.335 (95% CI, –0.18 to 0.85) additional QALYs. Intervention patients also had lower mean outpatient health costs of $594 per patient (95% CI, –$3241 to $2053) relative to UC patients.
Conclusions For adults with depression and poorly controlled diabetes, CHD, or both, a systematic intervention program aimed at improving depression scores and HbA1c, SBP, and LDL-C levels seemed to be a high-value program that for no or modest additional cost markedly improved QALYs.
Context Purpose in life is associated with a substantially reduced risk of Alzheimer disease (AD), but the neurobiologic basis of this protective effect remains unknown.
Objective To test the hypothesis that purpose in life reduces the deleterious effects of AD pathologic changes on cognition in advanced age.
Design A longitudinal, epidemiologic, clinicopathologic study of aging was conducted that included detailed annual clinical evaluations and brain autopsy.
Participants Two hundred forty-six community-based older persons from the Rush Memory and Aging Project participated.
Main Outcome Measures Purpose in life was assessed via structured interview, and cognitive function was evaluated annually and proximate to death. On postmortem examination, 3 indexes of AD pathologic features were quantified: global AD pathologic changes, amyloid, and tangles. The associations of disease pathologic changes and purpose in life with cognition were examined using linear regression and mixed models.
Results Purpose in life modified the association between the global measure of AD pathologic changes and cognition (mean [SE] parameter estimate, 0.532 [0.211]; P = .01), such that participants who reported higher levels of purpose in life exhibited better cognitive function despite the burden of the disease. Purpose in life also reduced the association of tangles with cognition (parameter estimate, 0.042 [0.019]; P = .03), and the protective effect of purpose in life persisted even after controlling for several potentially confounding variables. Furthermore, in analyses examining whether purpose in life modified the association between AD pathologic effects and the rate of cognitive decline, we found that higher levels of purpose in life reduced the effect of AD pathologic changes on cognitive decline (parameter estimate, 0.085 [0.039]; P = .03).
Conclusion Higher levels of purpose in life reduce the deleterious effects of AD pathologic changes on cognition in advanced age.
Context Depression and dementia are common in older adults and often co-occur, but it is unclear whether depression is an etiologic risk factor for dementia.
Objective To clarify the timing and nature of the association between depression and dementia.
Design We examined depressive symptoms assessed in midlife (1964-1973) and late life (1994-2000) and the risks of dementia, Alzheimer disease (AD), and vascular dementia (VaD) (2003-2009) in a retrospective cohort study. Depressive symptoms were categorized as none, midlife only, late life only, or both. Cox proportional hazards models (age as timescale) adjusted for demographics and medical comorbidities were used to examine depressive symptom category and risk of dementia, AD, or VaD.
Setting Kaiser Permanente Medical Care Program of Northern California.
Participants Thirteen thousand five hundred thirty-five long-term Kaiser Permanente members.
Main Outcome Measure Any medical record diagnosis of dementia or neurology clinic diagnosis of AD or VaD.
Results Subjects had a mean (SD) age of 81.1 (4.5) years in 2003, 57.9% were women, and 24.2% were nonwhite. Depressive symptoms were present in 14.1% of subjects in midlife only, 9.2% in late life only, and 4.2% in both. During 6 years of follow-up, 22.5% were diagnosed with dementia (5.5% with AD and 2.3% with VaD). The adjusted hazard of dementia was increased by approximately 20% for midlife depressive symptoms only (hazard ratio, 1.19 [95% CI, 1.07-1.32]), 70% for late-life symptoms only (1.72 [1.54-1.92]), and 80% for both (1.77 [1.52-2.06]). When we examined AD and VaD separately, subjects with late-life depressive symptoms only had a 2-fold increase in AD risk (hazard ratio, 2.06 [95% CI, 1.67-2.55]), whereas subjects with midlife and late-life symptoms had more than a 3-fold increase in VaD risk (3.51 [2.44-5.05]).
Conclusions Depressive symptoms in midlife or in late life are associated with an increased risk of developing dementia. Depression that begins in late life may be part of the AD prodrome, while recurrent depression may be etiologically associated with increased risk of VaD.
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Alice B. Toklas truly stirred the pot when she included a recipe for hashish fudge in her memoir-cum-cookbook. She published The Alice B. Toklas Cookbook in 1954, following the death of her lifelong...
Alice B. Toklas truly stirred the pot when she included a recipe for hashish fudge in her memoir-cum-cookbook. She published The Alice B. Toklas Cookbook in 1954, following the death of her lifelong...