Schizophrenia; Cognitive Enhancement; Pharmacological treatment
Services that provide comprehensive, early intervention (EI) have shown promise in improving long-term outcomes in schizophrenia. This paper reviews the rationale and salient concepts relevant to understanding the growing EI literature. A selective review of studies evaluating the effectiveness of integrated EI is followed by a discussion of feasibility, especially in the U.S. context. Finally, the authors present a framework that seeks to integrate activities traditionally categorized and separated as discovery and implementation. This framework is offered as one way to advance both goals.
first episode psychosis; critical period; schizophrenia; early intervention; knowledge translation
There is a large literature on the neuroanatomy of late-life depression which continues to grow with the discovery of novel structural imaging techniques along with innovative methods to analyze the images. Such advances have helped identify specific areas as well characteristic lesions in the brain and changes in the chemical composition in these regions that might be important in the pathophysiology of this complex disease. In this article we review the relevant findings by each structural neuroimaging technique. When validated across many studies, such findings can serve as neuroanatomic markers that can help generate rational hypotheses for future studies to further our understanding of geriatric depression.
Geriatric depression; late life depression; neuroimaging; MRI; white matter hyperintensities; magnetic resonance spectroscopy
Antipsychotic; Polypharmacy; Combination; Reasons; Rationale; Correlates; Schizophrenia
Amygdala; Generalized anxiety disorder; Posttraumatic stress disorder; Panic disorder; Social anxiety disorder; Corticotropin-releasing factor
The authors present an overview of empirically supported psychosocial interventions for individuals with substance use disorders (SUDs), including recent advances in the field. They also identify barriers to the adoption of evidence-based psychosocial treatments in community-based systems of care, and the promise of leveraging technology (computers, web, mobile phone, and emerging technologies) to markedly enhance the reach of these treatments. Technology-based interventions may provide “on-demand,” ubiquitous access to therapeutic support in diverse settings. A brief discussion of important next steps in developing, refining, and disseminating technology-delivered psychosocial interventions concludes the review.
computer; psychosocial treatment; addiction; technology; mobile
This article reviews established and emerging treatment options for cannabis dependence. Cannabis dependence poses some distinct challenges for treatment providers. The evolving sociocultural context of cannabis use for medical purposes, policy liberalization, and societal normalization has contributed to decreased perceived risk and increased acceptability of use. Simultaneously, the comparatively lower “severity” of cannabis-associated consequences makes it more difficult for some users to recognize the impact of their use and establish an enduring commitment to change. As a result, many treatment seekers are reluctant to accept traditional abstinence-based goals.
Among treatment providers, consensus has not been established about the value of non-abstinence goals, such as moderation and harm reduction. Notwithstanding these challenges, the high prevalence of cannabis dependence, its strong association with co-morbid mental health problems, and the difficulty of achieving cannabis cessation ensure that many psychiatrists will face patients with cannabis dependence. While no pharmacotherapy has been approved for cannabis dependence, a number of promising approaches are in development. Psychotherapy studies are establishing a number of evidence-based models and techniques in the treatment resources for patients in need.
Cannabis; Marijuana; Endocannabinoids; Dependence; Withdrawal; Treatment; Therapy
Drug abuse; Drug dependence; Drug use; Epidemiology
Cocaine dependence continues to be a significant public health problem and no clearly effective pharmacotherapy has yet been identified. Substitution pharmacotherapy is an effective approach for treating opioid and nicotine dependence, and accumulating evidence indicates that stimulant pharmacotherapy for cocaine dependence is a promising strategy. Broadly, stimulant medications that produce behavioral arousal, and medications across several therapeutic classes can be considered psychostimulants. To date, the available evidence is strongest for amphetamine analogs or dopaminergic agents combined with contingency management behavioral interventions as potential psychostimulant treatments for cocaine dependence. Most psychostimulants are controlled substances with inherent risks of misuse and diversion, and their use in patients with active substance use disorders is complex. As stimulant substitution treatment models for cocaine dependence are developed, particular attention to patient risk stratification is needed.
Cocaine dependence; Psychostimulant; Substance abuse
Data are reviewed on the societal costs of major depressive disorder (MDD). Early-onset MDD is found to predict difficulties in subsequent role transitions, including low educational attainment, high risk of teen child-bearing, marital disruption, and unstable employment. Among people with specific social and productive roles, MDD is found to predict significant decrements in role functioning (e.g., low marital quality, low work performance, low earnings). MDD is also associated with elevated risk of onset, persistence, and severity of a wide range of chronic physical disorders as well as with increased early mortality due to an even wider range of physical disorders and to suicide. Although effectiveness trials show that expanded MDD treatment can reverse many of these adverse effects, only a minority of people with MDD receives treatment and the quality of treatment is unacceptably low among the majority of those in treatment.
Absenteeism; costs of illness; disability; illness burden; impairment; major depressive disorder
evening hyperphagia; nocturnal ingestions; eating disorder-not otherwise specified; cognitive behavior therapy; selective serotonin reuptake inhibitors; light therapy
The central nervous system control of energy balance is a multi-determined process involving a distributed and redundant network of communication that exists between various brain regions and the body. The brain continuously receives, processes, and issues autonomic and behavioral output commands to respond to internal signals of energy availability. These signals are communicated to the brain either through a humoral pathway via the circulatory system, or through neuronal communication via the vagus and spinal nerves. Environmental, emotional, rewarding, and learned factors influence the brain’s perception of these internal signals and ultimately promote behaviors that drive the system to conserve energy and ingest energy-dense foods in excess. Therefore, this review discusses the energy balance system under normal physiological conditions, as well as the processes that have evolutionarily developed to promote energy surplus.
Despite growing recognition of the problem, the obesity epidemic continues in the U.S., and obesity rates are increasing around the world. The latest estimates are that approximately 34% of adults and 15–20% of children and adolescents in the U.S. are obese. Obesity affects every segment of the U.S. population. Obesity increases the risk of many chronic diseases in children and adults. The epidemic of obesity arose gradually over time, apparently from a small, consistent degree of positive energy balance. Substantial public health efforts are being directed toward addressing obesity, but there is not yet clear evidence of success. Because of the complexity of obesity, it is likely to be one of the most difficult public health issues our society has faced.
Behavioral treatment should be the first line of intervention for overweight and obese individuals. This paper provides an overview of the structure and principles of behavioral weight loss treatment. The short- and long-term effectiveness of this approach is reviewed. Strategies for improving weight loss maintenance are described, including prolonging contact between patients and providers (either in the clinic or via Internet or telephone), facilitating high amounts of physical activity, and combining lifestyle modification with pharmacotherapy. Finally, innovative programs that can be used to disseminate behavioral approaches beyond traditional academic settings are discussed.
obesity; weight loss; dieting; lifestyle; behavioral
Substance use disorder; Heritability; MAOA; COMT; HTR2B
Somatoform disorders are common conditions, but the current diagnostic criteria are considered to be unreliable, based largely on medically unexplained symptoms. DSM-5 is considering other possible characteristics of somatizers including high utilization, dissatisfaction with care, and poor response to reassurance. This paper reviews the available literature for evidence to support these criteria, and evaluates if distinctive aspects of these characteristics exist in somatizers.
The Pubmed database was searched combining terms such as “somatoform disorder” with “reassurance,” “satisfaction,” and “utilization.” Articles were individually inspected.
Many studies report a deficit in long-term response to reassurance in somatizers; there was some evidence that patients respond initially to reassurance, followed by return of anxiety, leading to further reassurance seeking. There was insufficient evidence to support poor satisfaction with care as a characteristic of somatizers. While there is no standard criterion for high utilization, regardless of definition, evidence was found to support over-utilization, particularly in outpatient visits. However, no unique pattern of utilization was found that could identify somatizers within a broader group of high utilizers.
This review revealed evidence of over-utilization in many areas of healthcare, as well as poor long term response to reassurance in somatizers. Dissatisfaction with care, though, was not a consistent finding. It is difficult to study alternative diagnostic criteria for somatoform patients when the current criteria rest on so many problematic assumptions. Future research should attempt to validate criteria empirically in patient groups, with selection not based on medically unexplained symptoms.
Somatoform disorder; DSM; utilization; satisfaction; reassurance
Prevention; Selective/Indicated; Depression; Later life
Risk for the development of major depressive disorder (MDD) is likely influenced by an interacting set of genes and environments. Many elderly are exposed to a variety of potential MDD precipitants. Medical co-morbidities, high inflammatory states, care-giver stress, and cerebrovascular changes are often observed proximal to the development of an episode. Additionally, some adults have histories of exposure to environmental stressors such as early life traumas that may result in a life-long predisposition to MDD. Despite these exposures, many people do not develop MDD; and genetic influences are hypothesized to be one influence on vulnerability and resilience. Over the last seven years, several studies have examined a variety of genes for this gene × environment (G×E) interaction. Most have examined a length polymorphism in the promoter region for the serotonin transporter gene, but some have examined brain derived neurotrophic factor, various genes encoding for key players in the hypothalamic-pituitary-adrenal axis, as well as other genes involved in the monoaminergic, neuroendocrine, and inflammatory systems. There is marked variation in the design of these studies, as well as in the measures of environment, MDD, and genotyping. Interpreting the sometimes inconsistent findings among studies is complicated by this heterogeneity. However, some tentative trends have emerged. An overview is provided of both the methodologies and results of these studies, noting consistent trends as well as confounds. The progress made to date will hopefully inform the next generation of studies.
polymorphism; stress; elderly; geriatric; depression
Despite the benefits of treatment for late-life depression, we are faced with the challenges of underutilization of mental health services by older adults and non-adherence to offered interventions. This paper describes psychosocial and interactional barriers and facilitators of treatment engagement among depressed older adults served by community health care settings. We describe the need to engage older adults in treatment using interventions that: 1. target psychological barriers such as stigma and other negative beliefs about depression and its treatment; and 2. increase individuals’ involvement in the treatment decision-making process. We then present personalized treatment engagement interventions that our group has designed for a variety of community settings.
depression; geriatric; treatment engagement; adherence; community settings
Psychosis is common in late life and exacts enormous costs to society, affected individuals, and their caregivers. A multitude of etiologies for late-life psychosis exist, the two most prototypical being schizophrenia and psychosis of Alzheimer’s Disease (AD). As such, this review will focus on the non-affective, neuropsychiatric causes of chronic psychosis in the elderly, specifically schizophrenia, delusional disorder, and the psychosis of AD and other dementias. As evidenced in this review, the current research regarding the onset and course of late-life schizophrenia reflects a more favorable prognosis than that painted by the Kraepelinian notion of schizoprenia as “dementia praecox.” Antipsychotics are useful in controlling the symptoms of late-life schizophrenia, but their use among older adults warrants increased vigilance because of older adults’ increased proclivity to side effects. Psychosocial interventions can be effective, usually in conjunction with medication. Meanwhile, psychosis of AD occurs in nearly half of people with AD and is associated with increased hospitalizations, institutionalization, caregiver distress, and mortality. Despite the profound consequences of psychotic symptoms associated with dementias, the extant literature does not afford clinicians clear, consistent guidance on how to provide optimal treatment to specific patients. Second generation antipsychotics are usually the choice treatment for psychosis, but the black box warning regarding their associated 1–2% increased absolute risk in stroke and overall mortality in patients with dementia complicates their use. Using second generation antipsychotics in low doses for brief periods and discontinuing them when possible is the best clinical practice for dementia-related psychosis. Psychosocial interventions for the treatment of psychosis with AD appear promising in empirical research, but more rigorous study is needed.
schizophrenia; psychosis; late-life; dementia; age
Despite pioneering findings on immune functions in various depressive syndromes, few recent studies focus on the role of inflammation and its potential in generating novel antidepressant therapies. We suggest that geriatric depression is the behavioral syndrome par excellence in which inflammatory processes are likely to play an etiological role. We base this assertion on the following observations: Geriatric depression occurs in the context of medical and neurological illnesses in which inflammatory processes are part of their pathogenesis. Both aging and depression are associated with pronounced and prolonged immune responses. Brain areas related to mood processing, have increased inflammatory responses during aging. Moreover, the connectivity among mood regulating structures may be modulated by inflammatory responses. Geriatric depression exacerbates the pathology of its comorbid medical and neurological disorders raising the question whether depression-related inflammatory changes mediate the worsening of their outcomes. Finally, geriatric depression often occurs in persons exposed to chronic stress, a state precipitating geriatric depression and triggering pro-inflammatory responses.
The clinical lesson derived from the available information is that depressed older adults should be examined for inflammatory disorders or risk factors of inflammation. It is premature to use anti-inflammatory agents in the treatment of geriatric depression. However, treatment of co-morbid conditions increasing CNS inflammatory responses can have general health benefits and should be part of clinical practice. Neuroimaging may identify microstructural abnormalities and dysfunction of neural networks associated with inflammatory processes accompanying geriatric depression. Transgenic animal models may help to identify candidate anti-inflammatory agents that later may be tested in clinical trials of geriatric depression.
Immunity; aging; depression; geriatrics
The goal of this systematic review is to evaluate the efficacy of psychosocial interventions for the acute treatment of late-life depression and identify predictors of treatment outcomes and moderators of treatment effects. The results of the systematic review may help to advance the development of personalized psychosocial treatments for late-life major depression. Based on our criteria, Problem Solving Therapy (PST), Cognitive Behavioral Therapy (CBT), and Treatment Initiation and Participation Program (TIP) have supportive evidence of efficacy, pending replication. Even though the data on the predictors of treatment outcomes and moderators of treatment effects are still preliminary, it appears that baseline anxiety and stress level, personality pathology, endogenous depression, and reduced self-rated health are associated with worse depression outcomes. More research is also recommended to examine the moderating effects of baseline depression severity; for instance, our review indicates that Interpersonal Psychotherapy (IPT) may work better in participants with high baseline depression severity than in participants with low depression severity. Recommendations for future novel psychosocial interventions for the acute treatment of late-life major depression include application of these interventions in non-traditional settings, involvement of the caregivers in the treatment of cognitively and functionally impaired older adults with major depression, and expansion of research to include more racially and ethnically diverse populations as the samples of the examined studies is highly selective, i.e. overly healthy, cognitively intact, Caucasian, and highly educated.
Suicide; older adult; aged; prevention