Impact of sunlight on the age of onset of bipolar disorder.

OBJECTIVE: Although bipolar disorder has high heritability, the onset occurs during several decades of life, suggesting that social and environmental factors may have considerable influence on disease onset. This study examined the association between the age of onset and sunlight at the location of onset. METHOD: Data were obtained from 2414 patients with a diagnosis of bipolar I disorder, according to DSM-IV criteria. Data were collected at 24 sites in 13 countries spanning latitudes 6.3 to 63.4 degrees from the equator, including data from both hemispheres. The age of onset and location of onset were obtained retrospectively, from patient records and/or direct interviews. Solar insolation data, or the amount of electromagnetic energy striking the surface of the earth, were obtained from the NASA Surface Meteorology and Solar Energy (SSE) database for each location of onset. RESULTS: The larger the maximum monthly increase in solar insolation at the location of onset, the younger the age of onset (coefficient= -4.724, 95% CI: -8.124 to -1.323, p=0.006), controlling for each country's median age. The maximum monthly increase in solar insolation occurred in springtime. No relationships were found between the age of onset and latitude, yearly total solar insolation, and the maximum monthly decrease in solar insolation. The largest maximum monthly increases in solar insolation occurred in diverse environments, including Norway, arid areas in California, and Chile. CONCLUSION: The large maximum monthly increase in sunlight in springtime may have an important influence on the onset of bipolar disorder.

Relevance of exclusion criteria in antidepressant clinical trials: a replication study.

INTRODUCTION: Patients in clinical randomized controlled trials (RCTs) of antidepressants are different from those typically treated in clinical practice, which may affect the generalizability of data from RCTs. We attempted to replicate the work of Zimmerman and colleagues (Zimmerman M, Mattia JI, Posternak MA. Are subjects in phamacological treatment trials of depression representative of patients in routine clinical practice? Am J Psychiatry. 2002;159:469-473), demonstrating that most patients seeking clinical treatment of depression would not qualify for an RCT based on common exclusion criteria. METHODS: Eight hundred seventeen patients presenting to an outpatient private practice were evaluated by retrospective chart review. The 11 exclusion criteria outlined in the previous study were applied to a sample of 348 depressed adults to determine the percentage that would have qualified for an RCT. RESULTS: We have closely replicated the study of Zimmerman et al, finding that 91% of our sample would not qualify for an RCT based on presence of any of the 11 exclusion criteria. Prevalence of 7 criteria applied were found significantly different in our population when compared with the study of Zimmerman et al, yet exclusion rates came within 0.2%. When only the 5 most common criteria were applied, exclusion rates remained high. CONCLUSIONS: Some exclusion criteria are essential for ethical or diagnostic purposes or to reduce heterogeneity; others are somewhat arbitrary, widening the gap between research and clinical practice. Ninety-one percent of patients presenting for treatment of depression would not qualify for RCTs if the 11 exclusion criteria identified were applied; if a standard severity cutoff score and 4 criteria considered relevant to safety or diagnostic validity were used, nearly 75% would not qualify. Use of antidepressants in a typical clinical population is an extrapolation from research data.

Rational antidepressant selection: applying evidence-based medicine to complex real-world patients.

Every clinician faces the daily question of which antidepressant is best for a particular depressed patient. Double-blind studies submitted for U.S. Federal Drug Administration marketing approval include only the "purest" population of patients, and the American Psychiatric Association and other treatment guidelines often do not adequately address the complexities of developmental, family history, psychosocial, medical, and psychiatric comorbidity, and treatment-refractory issues that are seen in routine clinical practice. Long-term trends in depression treatment include ever-expanding choices among drugs, highly specific psychotherapies, and attempts to treat chronic and/or mild cases, with the goal of remission for all patients. We performed literature reviews and attempted to synthesize factors that may be useful in the application of evidence-based medicine in office-based psychiatric practice. We have found that factors influencing antidepressant selection include drug factors (including tolerability, interactions, and cost), depression subtype, psychiatric and medical comorbidity, and stage of life. In addition, patient preference for avoiding certain side effects and personal and family history of treatment response are helpful information. Most patients in the community would not fit strict antidepressant study criteria. Biologic markers predicting treatment response are not yet widely available, so the optimal choice of medication must be guided by detailed history.

Psychopharmaco-hazardology: major hazards of treating depression and anxiety.

Balancing the benefits and risks of prescribing psychotherapeutic drugs requires knowledge of both drug hazards as well as risk of untreated psychiatric illness. Screening for medical illnesses, substance abuse, suicidality, and unusual side effects is essential throughout treatment.

Psychopharmacohazardology: major hazards of the new generation of psychotherapeutic drugs.

Balancing the benefits and risks of prescribing psychotherapeutic drugs requires knowledge of the baseline risks of genetics, lifestyle and morbidity of untreated illness. Superimposed upon these risks are some rare but potentially dangerous, uncomfortable or irreversible hazards of the antipsychotics, mood stabilizers, antidepressants and tranquillizers. Knowledge of these hazards facilitates monitoring and prompt intervention at the earliest sign of problems.