Aripiprazole as an adjunctive treatment for refractory unipolar depression.

INTRODUCTION: Aripiprazole may be an effective adjunctive treatment in outpatients with unipolar depression that has been refractory to treatment with SSRI or SNRI medication. METHODS: Fifteen subjects with a current DSM-IV diagnosis of MDD which had not responded to SSRI or SNRI treatment were enrolled in a 12 week open-label study of aripiprazole with a maximum dose of 30 mg/day. Patients' current episode averaged 10.4+/-16.6 years, with a range of 3 months to 54 years. Baseline severity averaged 30.1+/-7.1 on HDRS-24, and 19.7+/-8.4 on BDI. Patients had been treated with a mean dose of 79.2+/-28.2 mg/day of fluoxetine equivalents for an average of 1 year prior to starting the study. Five subjects were on SNRI medications and 10 on SSRIs. RESULTS: Seven of 14 (50.0%) subjects were classified as treatment responders, as defined by at least 50% reduction in the HDRS-24 at week 12. Four subjects (28.6%) achieved remission, based on STAR D criteria (HDRS-17 score

Can telepsychiatry replace in-person psychiatric assessments? A review and meta-analysis of comparison studies.

OBJECTIVE: The authors conducted a review and meta-analysis of the literature comparing telepsychiatry with "in-person" psychiatric assessments. METHOD: Approximately 380 studies on telepsychiatry published between 1956 and 2002 were identified using MEDLINE, PsycINFO, and cross-referenced bibliographies. Of these, 14 studies with an N > 10 compared telepsychiatry with in-person psychiatry (I-P) using objective assessment instruments or satisfaction instruments. Three of these studies compared high bandwidth (HB) with low bandwidth (LB) telepsychiatry. RESULTS: Fourteen studies of 500 patients met inclusion criteria and were included in the meta-analysis. Telepsychiatry was found to be similar to I-P for the studies using objective assessments. Effect sizes were on average quite small, suggesting no difference between telepsychiatry and I-P. Bandwidth was found to be a significant moderator. Three moderators were tested, effect sizes remained largely heterogeneous, and further analyses are needed to determine the direction of effect. There was no difference between I-P and telepsychiatry between the HB and LB groups, although there are anecdotal data suggesting that HB was slightly superior for assessments requiring detailed observation of subjects. CONCLUSION: Out of a large telepsychiatry literature published over the past 40+ years, only a handful of studies have attempted to compare telepsychiatry with I-P directly using standardized assessment instruments that permit meaningful comparisons. However, in those studies, the current meta-analysis concludes there is no difference in accuracy or satisfaction between the two modalities. Over the next few years, we expect telepsychiatry to replace I-P in certain research and clinical situations.

Hollywood portrayals of child and adolescent mental health treatment: implications for clinical practice.

This article examines the portrayals and myths of child and adolescent psychiatry relevant to the current practitioner. Although behavioral and emotional problems abound onscreen, the formal diagnosis of youth mental illness is uneven and rare. Common myths of brainwashing, incarceration, parent blame, parent supplantation, violence, and evil are explored, with current commercial examples of each. The impact of these portrayals on young patients, peers, parents, and the public at large are examined through the prevalence of different stereotypes across different genres more likely viewed by different ages. Positive and negative depictions of illness and treatment are identified for education and awareness, and the authors provide advice for using Hollywood films successfully as a helpful intervention in the mental health treatment of children and adolescents.

Citalopram in the treatment of dysthymic disorder.

This study aimed to provide preliminary data on the tolerability and effectiveness of citalopram for patients with dysthymic disorder. Twenty-one adult subjects meeting DSM-IV criteria for dysthymic disorder were enrolled in this 12-week open-label study, of whom 15 had pure dysthymia (e.g. no major depression in the past 2 years). Citalopram was initiated at 20 mg/day, and increased to a maximum of 60 mg/day. Response was defined as 50% or greater drop in score on the Hamilton Depression Rating Scale (HDRS) and a Clinical Global Impressions-I score of 1 ('very much improved') or 2 ('much improved'). Of these 15 pure dysthymic disorder subjects, all completed the trial, and 11 (73.3%) were treatment responders. All paired sample t-tests were highly significant, demonstrating significant average improvement on all measures of symptomatology and functioning. Scores on the 24-item HDRS decreased from 22.3+/-4.3 at baseline to 9.1+/-7.8 at week 12 [t(14)=6.1, P<0.001]. In addition, improvement was noted in self-reported measures of temperament and social functioning. The average final dose of citalopram was 39 mg/day. Side-effects were reported by nine of 15 subjects (60%), most frequently gastrointestinal symptoms (n=5), dry mouth (n=5) and sexual side-effects (n=3). These findings suggest the effectiveness and tolerability of citalopram in treating dysthymic disorder. Double-blind prospective studies are needed comparing citalopram both to placebo and to other medications, assessing both initial and sustained response to treatment.

A review of the costs of telepsychiatry.

OBJECTIVE: S: The issue of whether telepsychiatry is worth the cost or whether it pays for itself is controversial. This study investigated this question by reviewing telepsychiatry literature that focused on cost. METHOD: S: Approximately 380 studies on telepsychiatry published from 1956 through 2002 were identified through MEDLINE, PsycINFO, and cross-referenced bibliographies. Of these, 12 studies with samples of more than ten persons or programs focused specifically on the cost of telepsychiatry. RESULTS: The methods of examining cost used in the 12 studies were cost-feasibility, cost surveys, direct comparison of costs of telepsychiatry and in-person psychiatry, and cost analysis. It was concluded that in seven of the studies reported, telepsychiatry was worth the cost. One study reported that telepsychiatry was not financially viable. Three studies of cost-effectiveness reported the break-even number of consultations, the number that make telepsychiatry comparable in cost to in-person psychiatry. One review concluded that the lack of a clear business plan contributed to the difficulty of determining whether any of the programs was cost-effective. CONCLUSION: S: Telepsychiatry can be cost-effective in selected settings and can be financially viable if used beyond the break-even point in relation to the cost of providing in-person psychiatric services. Whether governmental or private health agencies value telepsychiatry enough to assume its cost is a question that remains to be answered.

Legal and ethical challenges in telepsychiatry.

Telepsychiatry in the 21st century poses a wide range of legal and ethical challenges. The authors review issues related to licensure, credentialing, privacy, security, confidentiality, informed consent, and professional liability in the use of telepsychiatry services and illustrate the discussion with hypothetical clinical vignettes. It is clear that there will be a need in the immediate future to create legal instruments as well as formal professional ethical guidelines for the practice of telepsychiatry.

Escitalopram versus placebo in the treatment of dysthymic disorder.

Numerous studies have assessed the acute efficacy of antidepressants, including selective serotonin reuptake inhibitors, in treating dysthymic disorder; however, escitalopram, the S-enantiomer of citalopram, has not been studied. Thirty-six outpatients with Structured Clinical Interview for DSM-III-R-diagnosed dysthymic disorder, aged 23-65 years (mean±SD=44.7±11 years), were randomly assigned to double-blind escitalopram (maximum dose 20 mg/day) versus placebo for 12 weeks. Inclusion criteria included age 18-65 years and Hamilton Depression Rating Scale (HDRS) score≥12. We hypothesized that escitalopram would be superior to placebo in the HDRS-24 item total score at week 12. We also hypothesized the superiority of escitalopram over placebo for secondary measures, including the percentage of participants classified as responders and remitters, as well as social functioning (Social Adjustment Scale), clinical global impression-improvement, Global Assessment of Functioning Scale. Participants' baseline HDRS-24 averaged 23.4±5.9. Final HDRS-24 scores at last observation carried forward did not differ significantly between escitalopram-treated (mean±SD=10.88±5.83) and placebo-treated individuals (mean±SD=16.4±6.34) (F=2.82, degrees of freedom=1,32, P=0.10). Significant differences favoring active medication were found on the Social Adjustment Scale and the Clinical Global Impression Severity and Global Assessment of Functioning Scale, but not in the percentages of responders or remitters. A larger study sample or higher escitalopram dose may show more significant placebo-medication differences.