Predictors of response to Systems Training for Emotional Predictability and Problem Solving (STEPPS) for borderline personality disorder: an exploratory study.

OBJECTIVE: Few predictors of treatment outcome or early discontinuation have been identified in persons with borderline personality disorder (BPD). AIM: The aim of the study was to examine the relationship between baseline clinical variables and treatment response and early discontinuation in a randomized controlled trial of System Training for Emotional Predictability and Problem Solving, a new cognitive group treatment. METHOD: Improvement was rated using the Zanarini Rating Scale for BPD, the Clinical Global Impression Scale, the Global Assessment Scale and the Beck Depression Inventory. Subjects were assessed during the 20 week trial and a 1-year follow-up. RESULTS: Higher baseline severity was associated with greater improvement in global functioning and BPD-related symptoms. Higher impulsivity was predictive of early discontinuation. Optimal improvement was associated with attending > or = 15 sessions. CONCLUSION: Subjects likely to improve have the more severe BPD symptoms at baseline, while high levels of impulsivity are associated with early discontinuation.

The Iowa record-linkage study. II. Excess mortality among patients with organic mental disorders.

Of 543 patients with organic mental disorders hospitalized at the University of Iowa Psychiatric Hospital, Iowa City, during a ten-year period, 87 died. This mortality was significant based on a control population. Patients of all ages were at risk for early death, especially those younger than 40 years. Risk was greatest during the first two years of follow-up; thereafter the observed death rate approached the expected rate. Patients were at special risk for death from "natural" causes, particularly cancer and heart disease among women, and influenza or pneumonia or "other" natural causes among men. During the first two years of follow-up, men were also at risk for death from accidents or suicide. Women with alcohol- and drug-related psychoses were at risk for death early in follow-up, but the diagnosis was not associated with risk from "unnatural death" in either sex.

The Iowa record-linkage study. I. Suicides and accidental deaths among psychiatric patients.

In a prospective investigation of 5,412 formerly hospitalized psychiatric patients, 68 committed suicide and 38 died from accidental causes. Both figures are significantly in excess of expectations based on a relevant control population. Those at significant risk included men and women of all ages, except those older than 69 years. Comparison of standardized mortality ratios suggests relatively greater risk for women and young persons. Risk for suicide was significant for patients of both sexes with acute schizophrenia, schizophrenia, affective disorders, and alcohol and other drug abuse, for men with neuroses, and for women with depressive neuroses. Risk for accidental death was greatest for those aged from 30 to 49 years and for those with personality disorders.

The Iowa record-linkage study. III. Excess mortality among patients with 'functional' disorders.

Our investigation of the pattern of mortality among former inpatients in nine diagnostic groups was based on deaths found among 4,869 former inpatients of the University of Iowa Psychiatric Hospital, Iowa City, during a ten-year period. Comparisons were made with expected values based on a relevant Iowa control population. The first two years of follow-up was a period of great risk but not after. Excessive mortality from "unnatural" causes was found among patients of either sex with an affective disorder, schizophrenia, alcohol or other drug abuse, and personality disorders, among men with acute schizophrenia or neuroses, and among women with depressive neuroses. Women with acute schizophrenia or a psychophysiologic disorder or special symptom were at risk for a "natural" death. These findings confirm the risk of reduced life span that patients in all nine categories share.

Suicide in subtypes of major affective disorder. A comparison with general population suicide mortality.

We investigated the risk of suicide among 705 patients with primary unipolar depression, 302 patients with secondary unipolar depression, and 586 patients with bipolar affective disorder (BAD). The suicide rates among the study subjects were compared with that of the general population of Iowa, the area from which the subjects were selected. An increased risk of suicide was found in all psychiatric groups, except the group of female patients with BAD, which was associated with a lower risk of suicide than unipolar disorders. Thirty suicides (73.2%) occurred during the first two years of follow-up; this trend was particularly pronounced in female patients with primary unipolar depression and male patients with BAD.

Architecture of research in psychiatry, 1953 to 1983.

Although there has been one report on the trends in study design in general medicine, we are aware of none for general psychiatry prior to this communication. Accordingly, articles from the American Journal of Psychiatry (N = 194) and the Archives (N = 109) were randomly sampled for the years 1953, 1963, 1973, and 1983. Two raters achieved reliability (kappa = .82) for recognizing the major types of study design (cohort, clinical trial, case control, cross sectional, case report, and review). There was a significant change in study architecture over time, with the percentage of review articles declining and the percentage of case-control and cross-sectional studies increasing. Another major finding was a large increase in use of inclusion and exclusion criteria for diagnosis in non-review article studies. The general trends are for increasingly sophisticated research designs to be used in psychiatry research. The quality of research designs in psychiatry for 1983 also compares favorably with research designs found in a respected medicine journal.

Diagnostic criteria for melancholia. The comparative validity of DSM-III and DSM-III-R.

The psychometric properties and validity of the DSM-III and DSM-III-R definitions of melancholia were examined in 60 depressed inpatients. The prevalence of melancholia was significantly higher according to the DSM-III-R criteria, and the kappa-coefficient of agreement between the two definitions was .40. For both criteria sets, the internal consistencies and item-scale correlations were low. Both definitions were associated with overall symptom severity and the melancholia symptom subscale; however, only DSM-III melancholics scored higher on the nonmelancholia symptom subscale. The DSM-III-R criteria were associated with more of the predicted correlates of endogenous subtyping. According to both definitions, melancholics were characterized by less stress, greater symptom severity, and less frequent nonserious suicide attempts prior to admission. The DSM-III-R melancholic subtyping was additionally associated with a family history of antisocial personality and substance abuse, presence of a premorbid personality disorder, age, and a tendency to blame others for the depression.

Excess mortality among formerly hospitalized child psychiatric patients.

Mortality was investigated in 881 male and 450 female formerly hospitalized child psychiatric patients in a four- to 15-year follow-up. Death from natural causes was not increased, but death from unnatural causes occurred at a rate more than twice as high as expected based on age- and sex-matched comparisons with the general population of the state of Iowa. Increased risk of unnatural death was found in five of eight psychiatric diagnostic categories but was significant only for Mental Reasoning, a category that combined patients with organic mental disorders, schizophrenia, or mental retardation. Clinical variables associated with an excess rate of unnatural death included age 15 years or older at the time of admission, the absence of a second psychiatric diagnosis, the presence of previous psychiatric hospitalizations, and the presence of a seizure disorder. Among the 23 unnatural deaths, the 11 (47.8%) suicides were excessive, but accidents and homicides were not.

A comparison of fluvoxamine, cognitive therapy, and placebo in the treatment of panic disorder.

Seventy-five outpatients with moderate to severe panic disorder were randomly assigned to receive 8 weeks of fluvoxamine, cognitive therapy, or placebo. Fifty-five patients completed the treatment protocol. Fluvoxamine was found to be an effective and well-tolerated treatment for panic using clinician- and patient-rated variables. Subjects receiving cognitive therapy also showed improvement, but this improvement did not significantly differ from the experience of the placebo-treated group for most comparisons. Fluvoxamine was superior to cognitive therapy for many ratings, but cognitive therapy was not superior to fluvoxamine on any rating. Fluvoxamine also produced improvement earlier than cognitive therapy. At the main comparison point (week 4), 57% (13/23) of patients receiving fluvoxamine were rated moderately improved or better vs 40% (8/20) of the group given cognitive therapy and 22% (5/23) of the placebo-treated group. At that point, 43% (10/23) of the fluvoxamine recipients vs 25% (5/20) of cognitive therapy and 4% (1/23) of placebo recipients were free of panic attacks.

The prediction of suicide. Sensitivity, specificity, and predictive value of a multivariate model applied to suicide among 1906 patients with affective disorders.

Stepwise multiple logistic regression was utilized in an attempt to develop a statistical model that would predict suicide in a group of 1906 Iowans with affective disorders admitted to a tertiary care hospital. The risk factors identified by this approach included the number of prior suicide attempts, suicidal ideation on admission, bipolar affective disorder (manic or mixed type), gender, outcome at discharge, and unipolar depressive disorder in individuals with a family history of mania. However, the model failed to identify any of the patients who committed suicide. The results appear to support the contention that, based on present knowledge, it is not possible to predict suicide, even among a high-risk group of inpatients.

Complicated mania. Comorbidity and immediate outcome in the treatment of mania.

In a case-control study, 57 manics with antecedent or coexisting nonaffective psychiatric disorders (n = 38) or serious medical illnesses (n = 19) ("complicated mania") were compared with 114 age-, sex-, and year-of-admission-matched controls with no other disorder ("uncomplicated mania"). Significant differences emerged between the three groups in age, marital status, age at onset, number of prior hospitalizations and prior suicide attempts, organic features, and outcome measures (recovery and death rates). Patients were divided into four treatment groups based on primary mode of therapy during index admission; the groups included electroconvulsive therapy, adequate lithium carbonate, inadequate lithium carbonate, and neither treatment. Uncomplicated manics were significantly more likely to receive adequate lithium carbonate and less likely to receive inadequate lithium carbonate than were complicated manics. The latter patients had a significantly poorer immediate response to treatment overall, and to adequate lithium carbonate specifically. Seventy-eight (68.4%) uncomplicated manics had recovered ad discharge, compared with 26 (45.6%) complicated manics. Logistic regression suggested that the influence of comorbidity on outcome was more important for women than men. We conclude that complicated mania is a useful clinical construct.

A family study of obsessive-compulsive disorder.

First-degree relatives of probands with obsessive-compulsive disorder (OCD) (n = 32) and psychiatrically normal controls (n = 33) were blindly interviewed with the use of the Diagnostic Interview Schedule. The morbidity risk for anxiety disorders was increased among the relatives of obsessional subjects compared with that for the relatives of controls, but the risk for OCD was not. Risk for a more broadly defined OCD (including relatives with obsessions and compulsions not meeting criteria for OCD) was increased among the parents of obsessional subjects but not among the parents of controls (16% vs 3%). The findings suggest that an anxiety disorder diathesis is transmitted in families with OCD, but that its expression within these families is variable. The findings also support the current practice of classifying OCD as an anxiety disorder.

Effect of axis II diagnoses on treatment outcome with clomipramine in 55 patients with obsessive-compulsive disorder.

We used the Structured Interview for DSM-III Personality Disorders to diagnose DSM-III personality disorders systematically in 55 patients with obsessive-compulsive disorder in the active-treatment cell of a controlled trial of clomipramine hydrochloride. Patients with a cluster A personality disorder had significantly higher obsessive-compulsive disorder severity scores at baseline, and the number of personality disorders was strongly related to baseline severity of obsessive-compulsive disorder symptoms. At the conclusion of the 12-week study, we found no significant difference in treatment outcome with clomipramine between those patients with at least one personality disorder and those with no personality disorders. However, the presence of schizotypal, borderline, and avoidant personality disorders, along with total number of personality disorders, did predict poorer treatment outcome. These variables were strongly related to having at least one cluster A personality disorder diagnosis, which was also a strong predictor of poorer outcome. Implications of these findings are discussed.

Lack of linkage to chromosome 5q11-q13 markers in six schizophrenia pedigrees.

We examined linkage between schizophrenia and five genetic markers on chromosome 5 in six pedigrees. Analyses were run considering the affected phenotype to be schizophrenia, schizophrenia plus a spectrum of related disorders, and these disorders plus any axis I diagnosis. None of the analyses were suggestive of linkage at any of the markers, either considering the pedigrees individually or in the aggregate. In our pedigrees, multipoint linkage analyses excluded much of the region that had supported linkage in an earlier study. These findings are consistent with other attempts to replicate the chromosome 5 linkage finding.

Multicenter double-blind comparison of sertraline and desipramine for concurrent obsessive-compulsive and major depressive disorders.

BACKGROUND: Serotonin reuptake inhibitors (SRIs) have demonstrated consistent efficacy in the treatment of obsessive-compulsive disorder (OCD), while agents that are primarily norepinephrine reuptake inhibitors have not. Comparable efficacy has been demonstrated for SRI and non-SRI antidepressants in uncomplicated major depressive disorder (MDD). This multicenter trial is the first comparison of an SRI (sertraline) and a non-SRI antidepressant (desipramine) in the treatment of OCD with concurrent MDD. METHODS: One hundred sixty-six patients diagnosed using structured clinical interviews and recruited from 16 treatment sites were randomly assigned to double-blind treatment with either sertraline (up to 200 mg/d) or desipramine (up to 300 mg/d) over 12 weeks. Measures of severity of OCD and MDD symptoms, as well as adverse effects of the medications, were monitored over the course of the treatment period. RESULTS: Patients assigned to sertraline responded significantly better at end point on measures of OCD and MDD symptoms compared with patients assigned to desipramine. Sertraline was also associated with a significantly greater number of patients who achieved a "robust" improvement in OCD symptoms (> or =40% reduction) compared with desipramine. More patients receiving desipramine than sertraline discontinued treatment because of adverse events. CONCLUSIONS: The SRI sertraline was more effective in reducing MDD and OCD symptoms than the primarily norepinephrine reuptake inhibitor desipramine for patients with concurrent OCD and MDD.

Multiple chemical sensitivity syndrome: symptom prevalence and risk factors in a military population.

OBJECTIVE: To assess the prevalence of and risk factors for self-reported symptoms suggestive of multiple chemical sensitivities/idiopathic environmental intolerance (MCS/IEI) in Persian Gulf War (PGW) veterans from Iowa and a comparison group of PGW-era military personnel. METHODS: A population-based sample of Iowa military personnel was surveyed using a cross-sectional telephone interview. Study participants were randomly drawn from 1 of 4 domains: PGW active duty, PGW National Guard/Reserve, non-PGW active duty, and non-PGW National Guard/Reserve. A complex sample survey design was used selecting participants from the following substrata: age, sex, race, rank, and military branch. The criteria for MCS/IEI were developed using expert consensus and the medical literature. RESULTS: A total of 3695 study participants (76% of those eligible) completed the telephone survey. The prevalence of symptoms suggestive of MCS/IEI in all participants was 3.4%. Veterans of the PGW reported a significantly higher prevalence of symptoms suggestive of MCS/IEI than did non-PGW military personnel (5.4% vs 2.6%); greater sensitivity to organic chemicals, vehicle exhaust, cosmetics, and smog; and more lifestyle changes. The following risk factors for MCS/IEI were identified with univariate analysis: deployment to the Persian Gulf, age (>25 years), female sex, receiving a physician diagnosis of MCS, previous professional psychiatric treatment, previous psychotropic medication use, current psychiatric illness, and a low level of preparedness. Multiple logistic regression analysis identified several independent risk factors for MCS/IEI, including deployment to the Persian Gulf, age, sex, rank, branch of service, previous professional psychiatric treatment, and current mental illness. CONCLUSIONS: Self-reported symptoms suggestive of MCS/IEI are relatively frequent in a military population and are more common among PGW veterans than comparable controls. Reported chemical sensitivities and accompanying behavioral changes were also frequent. After adjusting for age, sex, and training preparedness, previous professional psychiatric treatment and previous psychotropic medication use (before deployment) showed a robust association with symptoms suggestive of MCS.

DST nonsuppressor status: relationship to specific aspects of the depressive syndrome.

Using a conservative definition of suppressor status in hospitalized depressives, we found a relationship between abnormal endocrine function and certain kinds of depressive symptoms, i.e., melancholic symptoms, delusions, and memory deficit. Normal suppressor status is related to an early age of onset, absence of delusions, absence of memory deficit, absence of melancholia symptoms, and a presence of a diagnosis of secondary depression or a family history of alcoholism in depressives. The data suggest the distinction between neurotic-reactive depression and endogenous depression. It is equally important to note that these specific symptoms and characteristics possibly are associated with suppressor status independently of each other.

Predictors of immediate response in the treatment of mania: the importance of comorbidity.

Four hundred thirty-eight bipolar manics were admitted to an acute care psychiatric inpatient ward over a 12-year period. Eighty percent had good and 20% poor immediate outcome. Good outcome patients were characterized by short episode duration, older age of onset, a longer hospitalization, fewer suicide thoughts, and less psychiatric and medical comorbidity than the poor outcome group. Patients were divided into four treatment groups based on primary mode of therapy during index hospitalization: electroconvulsive therapy (ECT), adequate lithium, inadequate lithium, and neither treatment. Patients experiencing good outcome were more likely to be in the adequate lithium group and less likely to receive neither treatment. Regression analysis identified the absence of comorbidity, duration of lithium treatment more than 2 weeks, and duration of episode of less than 1 month as predictors of good outcome at hospital discharge.

Tritiated imipramine binding in obsessive-compulsive volunteers and psychiatrically normal controls.

The authors evaluated platelet tritiated imipramine binding in 22 outpatients with obsessive-compulsive disorder (OCD) and 22 psychiatrically normal controls matched for age and gender. Mean maximal binding site density (Bmax) and equilibrium dissociation affinity (Kd) values were not significantly different. In OCD patients, Bmax was positively associated with age but was not associated with age of onset, gender, personality disorder, or five measures of illness severity. Eight patients with OCD were subsequently treated with clomipramine up to 300 mg/day for 10 weeks. Among these 8 patients, Bmax values had a 65% mean decrease from baseline, but Bmax values did not change among 7 OCD patients receiving placebo. The results suggest that a reduced density of tritiated imipramine binding sites may not be associated with OCD.

Psychiatric and medical diagnoses as risk factors for mortality in psychiatric patients: a case-control study.

On the basis of a case-control study, the authors conclude that former psychiatric inpatients are more likely than control subjects to die of both natural and unnatural causes within 2 years of discharge. Patients who committed suicide were more likely to have had a diagnosis of affective disorder (unipolar depression) or alcoholism. Those who died of natural causes were more likely to have been admitted with medical diagnoses; no specific psychiatric diagnoses were associated with these deaths. It is doubtful that medical illnesses caused psychiatric syndromes such as depression in these inpatients. Psychiatric and medical illnesses combined may increase a patient's likelihood of seeking psychiatric help and entering the hospital.