Factors Influencing Longitudinal Stair Climb Performance from Midlife to Early Late Life: The Study of Women's Health Across the Nation Chicago and Michigan Sites.

OBJECTIVES: To quantify the longitudinal change in stair climb performance (a measure indicative of both physical function and muscle power), determine whether physical activity is related to slower decline in performance, and to identify factors that modify the longitudinal change in performance among women from midlife to late life. DESIGN: Longitudinal cohort study with up to 15 study visits. SETTING: Two sites of the Study of Women's Health Across the Nation. PARTICIPANTS: Black (n=411) and white (N=419) women followed from median age 47.0 (44.6-49.6) to 62.0 (55.8-65.3) years. INTERVENTIONS: N/A. MEASUREMENTS: Performance on a stair climb test (ascend/descend 4 steps, 3 cycles) was timed. Physical activity (PA) was assessed using the Kaiser Physical Activity Survey (KPAS; possible range 0-15 points). Sociodemographic and health factors were assessed via self-report. BMI was calculated with measured height and weight. Mixed-effects regression modeled longitudinal change in stair climb performance. RESULTS: Average baseline stair climb time was 18.12 seconds (95% CI: 17.83-18.41), with 0.98% (95% CI: 0.84%-1.11%) annual slowing. In fully adjusted models, higher levels of PA were associated with faster stair climb times (2.09% faster per point higher, 95% CI: -2.87%- -1.30%), and black women had 5.22% (95% CI: 2.43%-8.01%) slower performance compared to white women. Smoking, financial strain, diabetes, osteoarthritis, fair/poor health, and stroke were associated with 3.36% (95% CI: 0.07%-6.65%), 7.56% (95% CI: 4.75%-10.37%), 8.40% (95% CI: 2.89%-13.92%), 8.46% (95% CI: 5.12%-11.79%), 9.16% (95% CI: 4.72%-13.60%), and 16.94% (95% CI: 5.37%-28.51%) slower performance, respectively. In separate models, higher BMI (per 1-unit), osteoarthritis, fair/poor health, and diabetes, were each associated with 0.06% (95% CI:0.04%-0.08%), 0.48% (95% CI:0.12%-0.84%), 0.81% (95% CI:0.35%-1.28%), and 0.84% (95% CI:0.22%-1.46%), additional slowing per year over time. CONCLUSION: Significant declines in function were evident as women transitioned from midlife to early late life. Declines were amplified by indicators of poor health, emphasizing the importance of health in midlife for promoting healthy aging.

Risk factors for major depression during midlife among a community sample of women with and without prior major depression: are they the same or different?

BACKGROUND: Women's vulnerability for a first lifetime-onset of major depressive disorder (MDD) during midlife is substantial. It is unclear whether risk factors differ for first lifetime-onset and recurrent MDD. Identifying these risk factors can provide more focused depression screening and earlier intervention. This study aims to evaluate whether lifetime psychiatric and health histories, personality traits, menopausal status and factors that vary over time, e.g. symptoms, are independent risk factors for first-onset or recurrent MDD across 13 annual follow-ups. METHOD: Four hundred and forty-three women, aged 42-52 years, enrolled in the Study of Women's Health Across the Nation in Pittsburgh and participated in the Mental Health Study. Psychiatric interviews obtained information on lifetime psychiatric disorders at baseline and on occurrences of MDD episodes annually. Psychosocial and health-related data were collected annually. Cox multivariable analyses were conducted separately for women with and without a MDD history at baseline. RESULTS: Women without lifetime MDD at baseline had a lower risk of developing MDD during midlife than those with a prior MDD history (28% v. 59%) and their risk profiles differed. Health conditions prior to baseline and during follow-ups perception of functioning (ps < 0.05) and vasomotor symptoms (VMS) (p = 0.08) were risk factors for first lifetime-onset MDD. Being peri- and post-menopausal, psychological symptoms and a prior anxiety disorder were predominant risk factors for MDD recurrence. CONCLUSIONS: The menopausal transition warrants attention as a period of vulnerability to MDD recurrence, while health factors and VMS should be considered important risk factors for first lifetime-onset of MDD during midlife.

Do anxiety symptoms predict major depressive disorder in midlife women? The Study of Women's Health Across the Nation (SWAN) Mental Health Study (MHS).

BACKGROUND: In women, anxiety symptoms are common and increase during midlife, but little is known about whether these symptoms predict onsets of major depressive disorder (MDD) episodes. We examined whether anxiety symptoms are associated with subsequent episodes of MDD in midlife African-American and Caucasian women, and whether they confer a different risk for first versus recurrent MDD episodes. METHOD: A longitudinal analysis was conducted using 12 years of data from the Study of Women's Health Across the Nation (SWAN) Mental Health Study (MHS). The baseline sample comprised 425 Caucasian (n=278) and African American (n=147) community-dwelling women, aged 46.1±2.5 years. Anxiety symptoms measured annually using a self-report questionnaire were examined in relation to MDD episodes in the subsequent year, assessed with the SCID. Multivariable models were estimated with random effects logistic regression. RESULTS: Higher anxiety symptoms scores were associated with a significantly higher adjusted odds of developing an episode of MDD at the subsequent annual visit [odds ratio (OR) 1.47, p=0.01], specifically for a recurrent episode (OR 1.49, p=0.03) but non-significant for a first episode (OR 1.32, p=0.27). There were no significant racial effects in the association between anxiety symptoms and subsequent MDD episodes. CONCLUSIONS: Anxiety symptoms often precede MDD and may increase the vulnerability of midlife women to depressive episodes, particularly recurrences. Women with anxiety symptoms should be monitored clinically during the ensuing year for the development of an MDD episode.

Major depression during and after the menopausal transition: Study of Women's Health Across the Nation (SWAN).

BACKGROUND: It is unclear whether risk for major depression during the menopausal transition or immediately thereafter is increased relative to pre-menopause. We aimed to examine whether the odds of experiencing major depression were greater when women were peri- or post-menopausal compared to when they were pre-menopausal, independent of a history of major depression at study entry and annual measures of vasomotor symptoms (VMS), serum levels of, or changes in, estradiol (E2), follicular stimulating hormone (FSH) or testosterone (T) and relevant confounders. METHOD: Participants included the 221 African American and Caucasian women, aged 42-52 years, who were pre-menopausal at entry into the Pittsburgh site of a community-based study of menopause, the Study of Women's Health Across the Nation (SWAN). We conducted the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID) to assess diagnoses of lifetime, annual and current major depression at baseline and at annual follow-ups. Psychosocial and health factors, and blood samples for assay of reproductive hormones, were obtained annually. RESULTS: Women were two to four times more likely to experience a major depressive episode (MDE) when they were peri-menopausal or early post-menopausal. Repeated-measures logistic regression analyses showed that the effect of menopausal status was independent of history of major depression and annually measured upsetting life events, psychotropic medication use, VMS and serum levels of or changes in reproductive hormones. History of major depression was a strong predictor of major depression throughout the study. CONCLUSIONS: The risk of major depression is greater for women during and immediately after the menopausal transition than when they are pre-menopausal.

Predictors of first lifetime episodes of major depression in midlife women.

BACKGROUND: Little is known about factors that predict first lifetime episodes of major depression in middle-aged women. It is not known whether health-related factors and life stress pose more or less of a risk to the onset of clinical depression than does the menopausal transition. METHOD: The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID) was used to assess diagnoses of lifetime, annual and current major depression in a community-based sample of premenopausal or early perimenopausal African American and White women. Menstrual cycle characteristics, psychosocial and health-related factors, and blood samples for assay of reproductive hormones were obtained annually. Two hundred and sixty-six women without a history of major depression at baseline constituted the cohort for the current analyses. RESULTS: Over 7 years of follow-up, 42 (15.8%) women met criteria for a diagnosis of major depression. Frequent vasomotor symptoms (VMS; hot flashes and/or night sweats) (HR 2.14, p=0.03) were a significant predictor of major depression in univariate analyses. After simultaneous adjustment for multiple predictors in Cox proportional hazards analyses, frequent VMS were no longer significant; lifetime history of an anxiety disorder (HR 2.20, p=0.02) and role limitations due to physical health (HR 1.88, p=0.07) at baseline and a very stressful life event (HR 2.25, p=0.04) prior to depression onset predicted a first episode of major depression. CONCLUSIONS: Both earlier (e.g. history of anxiety disorders) and more proximal factors (e.g. life stress) may be more important than VMS in contributing to a first episode of major depression during midlife.

Quality of life in diverse groups of midlife women: assessing the influence of menopause, health status and psychosocial and demographic factors.

This paper examines whether menopausal status is associated with global quality of life (QOL) among women aged 40-55 and whether this association varies by race/ethnicity. We further examine the contributions of other health-related and psychosocial factors to QOL and whether these associations vary by racial/ethnic group. Analyses are based on 13,874 women who participated in the multi-ethnic, multi-race study of mid-aged women called the Study of Women's Health Across the Nation (SWAN). Study participants completed a 15-min telephone or in-person interview that contained questions on a variety of health-related topics. Items of interest for these analyses include global QOL, menstrual history (to assess menopausal status), sociodemographics, health status, lifestyle, and psychosocial variables. Results showed that in unadjusted analyses, early perimenopausal women reported lower QOL compared with premenopausal women, but menopausal status was no longer associated with QOL when analyses were adjusted for other variables. In multivariable models, being married and having low levels of perceived stress were associated with better QOL across all racial/ethnic groups. While there were many consistencies across racial/ethnic groups, we also found that the nature of the associations between QOL and education, marital status, perceived stress and social support varied across racial/ethnic groups.

A population-based longitudinal study of cognitive functioning in the menopausal transition.

BACKGROUND: No longitudinal studies have tracked cognitive performance through the menopausal transition and thus the impact of the transition on cognition, independent of aging, is not known. The authors hypothesized that a decline in cognitive functioning occurs as women progress through the menopausal transition, independent of age, educational level, family income, ethnicity, and baseline self-perceived health. METHOD: The authors began a population-based, longitudinal study in January 1996 with yearly follow-up interviews. This report includes follow-up through November 2001. The authors randomly selected African American and white women from a census of two contiguous Chicago communities. After screening for eligibility (age 42 to 52 years, premenopausal or early perimenopausal, no exogenous hormone use in the past 3 months, and no hysterectomy), 868 agreed to participate. Women who became pregnant, had a hysterectomy, or began using hormones were censored from that time onward. This study reports on 803 women for whom cognitive assessments were available. The authors assessed working memory (Digit Span Backward) and perceptual speed (Symbol Digit Modalities Test). RESULTS: Contrary to the hypothesis, the authors found small but significant increases over time during the premenopausal and perimenopausal phases. This trend was not accounted for by chronological age, education, family income, ethnicity, or baseline self-perceived health. CONCLUSIONS: Transition through menopause is not accompanied by a decline in working memory and perceptual speed.

Psychologic distress and natural menopause: a multiethnic community study.

OBJECTIVES: This study examined the association between psychologic distress and natural menopause in a community sample of African American, White, Chinese, Hispanic, and Japanese women participating in a national women's health study. METHODS: A cohort of 16,065 women aged 40 to 55 years provided information on menstrual regularity in the previous year, psychosocial factors, health, and somatic-psychologic symptoms. Psychologic distress was defined as feeling tense, depressed, and irritable in the previous 2 weeks. RESULTS: Rates of psychologic distress were highest in early perimenopause (28.9%) and lowest in premenopause (20.9%) and postmenopause (22%). In comparison with premenopausal women, early perimenopausal women were at a greater risk of distress, with and without adjustment for vasomotor and sleep symptoms and covariates. Odds of distress were significantly higher for Whites than for the other racial/ethnic groups. CONCLUSIONS: Psychologic distress is associated with irregular menses in midlife. It is important to determine whether distress is linked to alterations in hormone levels and to what extent a mood-hormone relationship may be influenced by socioeconomic and cultural factors.

Recovery from a recurrent major depressive episode.

Episode-related factors and antidepressant treatment adequacy may be important determinants of recovery from a major depressive episode (MDE). We compared recovered and nonrecovered patients on baseline sociodemographic, clinical and episode-related measurements. Twenty-five inpatients with recurrent major depressive disorder diagnosed by SADS-L participated in this naturalistic, prospective, longitudinal study. Recovery, which was defined as a sustained return to non-depressed status lasting > or = 8 consecutive weeks, was assessed at 6- and 12-month follow-up with the Streamlined Longitudinal Interval Continuation Evaluation (SLICE). Thirteen (52%) patients met recovery criteria. The cumulative proportion remaining depressed for at least 52 weeks was 42.5%. Recovered patients had shorter episodes preceding the index hospitalization (P = .01). Despite adequate antidepressant pharmacotherapy, the length of the current episode remains the most important correlate of recovery from MDE recurrence. Our small sample size and the uncontrolled nature of treatment may limit the generalizability of these findings.

Characteristics of women in jail and treatment orientations. A review.

Women who have been incarcerated are a high-risk group for criminal recidivism, and criminal justice statistics indicate that females are increasing in numbers more rapidly than the male detainee population. According to data from epidemiologic studies, incarcerated women are often young, single, mothers from ethnic minority backgrounds who have little education and poor work histories. Mental illness, drug abuse, and risky behaviors relating to contracting HIV/AIDS are common problems among female detainees. In this report, research into characteristics of women in jail and literature relating to treatment programs for incarcerated women are reviewed. Implications relating to treatment needs, program development, and further research are discussed. A case example and treatment intervention are presented based on this review.

Pharmacological treatments for alcoholism: revisiting lithium and considering buspirone.

OBJECTIVE: Previous research has suggested that both lithium and buspirone could lessen alcoholics' desire to drink as well as reduce the actual amounts of alcohol consumed. The purpose of this study was to compare lithium and buspirone monotherapy with placebo on outcomes of abstinence, alcohol quantity consumed, treatment retention and compliance, and medication side effects. METHODS: We conducted a randomized, double-blind, placebo-controlled, three-arm parallel group, clinical trial that compared lithium and buspirone with placebo in 156 alcohol-dependent men. RESULTS: Study retention rates for the three treatment groups at 3 and 6 months, respectively, were 61% and 46% for lithium, 44% and 27% for buspirone, and 52% and 38% for placebo (p = NS, for 3 and 6 months). Overall abstinence rates were 28% and 19% at 3 and 6 months, respectively. However, mean daily quantities of alcohol consumed and percentage of drinking days decreased significantly (p < 0.0001) over time in all treatment groups. Differential improvement was seen only for the decrement in quantity consumed in the buspirone group, compared with the placebo group, but only at a trend level (p = 0.07). According to pill counts, compliance did not differ significantly among the treatment groups. CONCLUSIONS: These results do not support the hypothesis that either lithium or buspirone, compared with placebo, produces differential reductions in alcohol consumption. The results suggest the need to enhance treatment retention to maximize outcomes.

An outpatient psychiatry program for offenders with mental disorders found not guilty by reason of insanity.

OBJECTIVE: Rehospitalization and criminal recidivism were examined among a group of offenders with mental disorders adjudicated as not guilty by reason of insanity and mandated to receive treatment in a forensic psychiatric outpatient program as a condition of release. METHODS: A retrospective chart review was conducted for 43 offenders with mental disorders who were acquitted as being not guilty by reason of insanity for the index offense and were active in the outpatient treatment program in 1996. Data were abstracted on sociodemographic, psychiatric, and criminal characteristics predating the index offense; rehospitalizations and new crimes and rearrests after the offense; and clinical and psychosocial functional outcomes after enrollment in the outpatient program. RESULTS: For the 43 patients, the mean length of stay in the program was 68 months, with a range of 4.9 months to 18.4 years. Almost two-thirds of the patients were diagnosed as having schizophrenia, schizoaffective disorder, or a nonaffective psychotic disorder; 58 percent had a comorbid substance use disorder, and 63 percent had an axis II diagnosis. Since program enrollment, 20 patients (47 percent) were rehospitalized at least once, and eight (19 percent) were rearrested or had committed a new crime. At the end of 1996, only nine (24 percent) were in full remission, and 26 (68 percent) showed at least one indicator of difficulty reintegrating into the community. CONCLUSIONS: Even after treatment in a specialized forensic program, this sample of offenders with serious mental disorders remained impaired symptomatically and functionally. Although avoidance of rehospitalization is considered a successful outcome, rehospitalization is preferable to rearrest for this forensic population.

Treatment attrition among alcohol-dependent men: is it related to novelty seeking personality traits?

"Dropouts" are a major concern when monitoring treatment efficacy in clinical trials. Alcohol-dependent patients are especially prone to discontinuing treatment, perhaps because of impulsive behavior. The Tridimensional Personality Questionnaire (TPQ) measures a trait-like quality, novelty seeking, which may reflect impulsiveness. We tested the hypotheses that higher TPQ Novelty Seeking subscale scores would be associated with increased rates of treatment dropout and increased risk for dropping out earlier. A total of 170 alcohol-dependent men who participated in a double-blind, placebo-controlled pharmacotherapeutic trial for decreasing relapse drinking completed the TPQ and were monitored until treatment dropout. Logistic regression and Cox proportional hazards models were used to (1) describe the relationship between the TPQ Novelty Seeking score and the dichotomous outcome variable, treatment dropout; and (2) assess the effects of a number of potential confounding covariates on the relationship between the risk factor, novelty seeking, and the time to the outcome event. The mean Novelty Seeking score was significantly higher among study dropouts compared with nondropouts (p = 0.003). Higher Novelty Seeking scores were associated with a higher adjusted odds ratio for dropping out (adjusted odds ratio = 1.07, 95% confidence interval [CI] = 1.00-1.15) and a higher adjusted hazard rate for dropping out earlier (adjusted hazard rate = 1.05, 95% CI = 1.00-1.09). The TPQ Novelty Seeking subscale score may identify a subgroup of alcohol-dependent men who are at risk for dropping out of treatment. This information may be useful for developing treatment plans to encourage these high-risk patients to remain in treatment.

Suicide: a four-pathway clinical-biochemical model.

This chapter, based on a review of recent research as well as data presented in this report, proposes four hypothetical pathways leading to suicide in clinical depression: (1) an acute pathway involving severe anxiety/agitation associated with high brain corticotrophin-releasing factor (CRF or CRH) levels, (2) trait baseline and reactivity hopelessness, (3) severe anhedonia, and (4) trait impulsiveness associated with low brain serotonin turnover and low total cholesterol as a possible peripheral correlate. Clinical research showing evidence for acute versus chronic high-risk suicide factors and other studies linking severe anxiety/agitation to high CRF levels will be presented as associated with acute suicidal risk, which is potentially reversible with recognition and treatment. Evidence for anhedonia severity as a risk factor and trait, as well as evidence that baseline hopelessness and sensitivity are traits related to chronic suicide risk, will be presented. Finally, evidence relating low serum cholesterol to suicide in depressed inpatients will be presented in the context of literature suggesting a relationship between low serum cholesterol and violent death and suicide in population studies. Data suggesting a relationship between low serum cholesterol and decreased CSF 5-HIAA, suggesting reduced serotonin turnover, will be presented, in light of prior studies relating low CSF 5-HIAA and violent suicide. These data taken together suggest four pathways to suicide that are worth investigating in order to better understand the mechanisms leading to this behavior. Future possibilities and applications of these findings are discussed.

Cycle of abuse and psychopathology in cleric and noncleric molesters of children and adolescents.

Sexual abuse in childhood is frequently reported among sex offenders and has been hypothesized to be one of a number of psychological factors etiologically related to perpetration of child molestation in adulthood. In the current study we examine a sample of cleric and noncleric admitted child molesters and normal control subjects in their exposure to sexual abuse in childhood and current psychopathology. Odds ratios for the association between exposure to sexual abuse and child molestation were obtained while adjusting for group differences in demographic and psychological characteristics. Results indicated exposure to sexual abuse in childhood was associated with becoming a child molester for both cleric and noncleric offenders (p < .0002). Nonclerics indicated more severe psychopathology than clerics. Sexual abuse in childhood is one of many risk factors for becoming a perpetrator of child molestation in adulthood for both cleric and noncleric child molesters. Noncleric offenders demonstrated more sociopathy and mental disorder in general while cleric offenders indicated more sexual conflictedness, suggesting different psychoetiologies of offending among cleric and noncleric child molesters.

Psychological aspects of sexual functioning among cleric and noncleric alleged sex offenders.

Cleric sexual misconduct with minors is a problem receiving increased attention from the media, victims groups, and church authorities. Mental health professionals are increasingly being asked to assist church and civil authorities to help better understand the problem of cleric sexual misconduct with minors. In the current study we compared self-reported sexual functioning among cleric alleged child molesters, noncleric alleged child molesters, and normal control subjects. We hypothesized clerics would differ from nonclerics and normals in reported sexual functioning. Our sample included 30 Roman Catholic clerics and 39 nonclerics who were alleged to have engaged in sexual misconduct with minors, and 38 normal control subjects, all of whom took the Derogatis Sexual Functioning Inventory (DSFI) as part of their forensic psychiatric evaluation. Our results indicated clerics were more likely to report fewer victims, older victims, and victims of male gender than noncleric alleged child molesters. Clerics differed from nonclerics and normal control subjects on several dimensions of self-reported sexual functioning. Lower offense rate histories among clerics suggest that, as a group, clerics may be less seriously psychologically disordered than noncleric child molesters. Low DSFI scores among Roman Catholic clerics may be accounted for in part by their unique training and socialization process. Future studies should attempt to study the influence of social desirability on DSFI scores. Normative data from nonoffending celibate clergy are needed.

Fibromyalgia, depression, and alcoholism: a family history study.

OBJECTIVE: Fibromyalgia (FM) syndrome may be part of an "affective spectrum disorder." The diseases in this group have in common high rates of major depression in first degree relatives (FDR) and a response to antidepressant treatment. In this familial aggregation study, we tested the hypothesis that depression in patients with FM is related to a family history of depression or alcoholism in their FDR. METHODS: To assess the relationship between FM and lifetime histories of depression (DEP) and alcoholism (ALC), personal and family histories of mood and substance use disorders were obtained from 60 probands with FM. DEP and ALC among the probands were diagnosed using the Schedule for Affective Disorders and Schizophrenia, a standardized, structured psychiatric interview, and the Research Diagnostic Criteria (RDC). Family psychopathology in the FDR (parents, full siblings, children) was assessed using the Family History RDC. The odds ratio (OR) for DEP and/or ALC in FDR of probands with a history of DEP versus those without DEP were calculated. Confidence intervals (CI) not including 1 were significant at p < 0.05 (95% CI). RESULTS: The odds of identifying FDR with DEP and/or ALC were significantly higher among probands with FM with a lifetime history of DEP than among probands with FM who had no history of DEP (OR = 2.10, 95% CI = 1.23-3.57). This may be accounted for by the significantly higher odds for ALC among the FDR of probands with both FM and DEP compared with the FDR of probands with FM but no history of depression (OR = 2.30, 95% CI = 1.21-4.37). Although alcoholism was increased in the FDR of probands with FM with a history of depression, the odds for DEP were nonsignificantly higher among these FDR (OR = 1.71, 95% CI = 0.87-3.31). OR in the same range of magnitude were obtained when the data were analyzed by family unit, but these results were not statistically significant. CONCLUSION: Our data suggest that the tendency toward DEP in patients with FM may be a manifestation of a familial depressive spectrum disorder (alcoholism and/or depression in the family members), not simply a "reactive" depression secondary to the pain and other symptoms.

Medroxyprogesterone and paraphiles: do testosterone levels matter?

We examine the associations between pretreatment testosterone (TTS) levels and sociodemographic, clinical, and sexual behavioral characteristics. Two groups, low and normal pretreatment TTS, were treated with medroxyprogesterone acetate (MPA) and compared on clinical response (deviant and nondeviant sexual behaviors; recidivism) and length of time to return to pretreatment TTS after discontinuing MPA. Thirteen paraphilic men who were treated with MPA and had TTS levels monitored at approximately three-month intervals during and after MPA were followed naturalistically. The principal outcome measures pertained to TTS levels and data from a self-report psychosexual inventory, which quantified deviant and nondeviant sexual activities. Time to return to baseline TTS levels were analyzed with Kaplan-Meier survival analysis. Nonparametric methods were used to compare the two groups on other variables. Multiple regression was used to examine the contribution of combinations of variables to TTS outcome. Subjects with low pretreatment TTS received MPA for longer periods of time, and older subjects took longer to return to pretreatment TTS levels despite being treated for shorter periods of time. Although subjects with lower pretreatment TTS levels may be more sensitive to MPA's TTS-suppressive effects, the multiple regression analysis showed that age may be an important determinant of the time it take for TTS levels to return to pretreatment baseline. Sociodemographic, clinical, and self-reported measures of sexual behavior did not distinguish between low and normal TTS level groups. Only one relapse was detected. Further studies with larger samples are required to better understand the role of TTS monitoring of sex offenders treated with MPA, in order to justify its continued use as a measurement of treatment adequacy and to study its potential role as a predictor of treatment outcome.

Predicting the "revolving door" phenomenon among patients with schizophrenic, schizoaffective, and affective disorders.

OBJECTIVE: A subpopulation of chronically mentally ill patients, sometimes referred to as "revolving door" patients, are frequently readmitted to psychiatric units. This study examined the relationships among demographic features, diagnostic characteristics, and frequency of hospitalization of patients from four state hospitals. METHOD: Two semistructured, standardized instruments, the Schedule for Affective Disorders and Schizophrenia and a life events history, were administered to 135 inpatients who met the Research Diagnostic Criteria for schizophrenia (N = 56), schizoaffective disorder (N = 33), unipolar major depressive disorder (N = 23), and bipolar disorder (N = 23). Criminal history was assessed by arrest records. The main outcome measure was the number of hospitalizations. RESULTS: Chi-square and trend test analyses indicated that substance abuse and noncompliance with medication regimens were significantly associated with higher frequencies of hospitalization. A multiple regression model, which included alcohol/drug problems, medication noncompliance, and six sociodemographic and diagnostic variables (age, gender, race, marital status, years of education, and diagnosis) accounted for a significant proportion of the ability to predict frequency of hospitalization. Half of this predictability was due to the relationship of substance abuse and medication noncompliance with number of hospitalizations. CONCLUSIONS: Alcohol/drug problems and noncompliance with medication were the most important factors related to frequency of hospitalization. Preventing these behaviors through patient education may reduce rehospitalization rates.

Medroxyprogesterone treatment for paraphiliacs.

This study addresses the following questions: (1) what are the essential components of a medroxyprogesterone acetate (MPA) pretreatment evaluation?; (2) do paraphilic men treated with MPA (Depo-Provera) report a lowering of both deviant and nondeviant sexual drive and activities?; (3) is behavioral improvement associated with testosterone level reductions?; and (4) what significant side effects are associated with MPA treatment? A total of 29 paraphilic men who underwent a comprehensive psychiatric, medical, and legal evaluation and were eligible for treatment with MPA were followed naturalistically while receiving concurrent MPA and group therapy. The principal outcome measures were data obtained from a weekly self-reported psychosexual inventory that quantified five dimensions of deviant and nondeviant sexual activities and testosterone levels that were drawn pretreatment and after three and six months of MPA. Self-reported data were analyzed by nonparametric methods. Because MPA's effectiveness is evident early in treatment, we report on data from the first six months. Subjects reported a differential rate of suppression of sexual activities, a median of up to two weeks for deviant and 2 to 10 weeks for nondeviant behaviors (p < or = .01 for each of the five dimensions). Testosterone levels suppressed to less than 0.5 ng per milliliter for all but two subjects at three months and for all at six months. Recidivism was reported for one subject. Except for one subject who developed pulmonary emboli, no major medical problems were encountered. MPA safely and effectively reduced sex drive, controlled deviant sexual impulses and behavior, and lowered the testosterone levels of these paraphilic men during the first six months of treatment. However, the relative rapidity and completeness of the response raises questions regarding possible distortions in self-reported sexual activities. This should alert the practicing clinician to consider the use of collateral sources of information in interpreting treatment outcome for patients with paraphilic behaviors. Also, longer follow-up periods are required for monitoring treatment efficacy.