OBJECTIVE: Patients with bipolar disorder often report depressive symptoms that do not meet the DSM-IV criteria for an episode. Using daily self-reported mood ratings, we studied how changing the length requirement to that typical of recurrent brief depression (2-4 days) would impact the number of depressed episodes.
METHOD: 203 patients (135 bipolar I and 68 bipolar II by DSM-IV criteria) recorded mood daily using ChronoRecord software on a home computer (30,348 total days; mean 150 days). Episodes of depression and days of depression outside of episodes were determined. Symptom intensity (mild versus moderate or severe) was investigated within and outside of depressive episodes.
RESULTS: Decreasing the minimum duration criterion for an episode of depression to 2 days increased the number of patients with a depressed episode two and a half times (52 to 131), and quadrupled both the number of depressed episodes per patient (0.62 to 2.88) and the number of depressed episodes for all patients (125 to 584). With a 2-day episode length, 34% of days of depression remained outside an episode. The ratio of days with severe symptoms within episodes remained consistent (about 25%) in spite of decreasing the episode length to 2 days. Considering only days with severe symptoms, about 25% remained outside of episodes even with a 2-day length. None of the results distinguished bipolar I from bipolar II disorder.
LIMITATIONS: Self-reported data, computer access required, relatively short study length, no control group.
CONCLUSION: Brief depressive episodes and single days of depression outside of episodes occur frequently in both bipolar I and bipolar II disorder. Moderate or severe symptoms occur during brief episodes at a ratio similar to that for episodes that meet the DSM-IV criteria.
Self-reported data from patients with bipolar disorder: impact on minimum episode length for hypomania
OBJECTIVE: Some investigators have suggested decreasing the minimum hypomania episode length criterion from 4 days, as in the DSM-IV, to 2 days. Using daily self-reported mood ratings, we studied the impact of changing the length requirement on the number of hypomanic episodes in patients with bipolar disorder.
METHOD: 203 patients (135 bipolar I and 68 bipolar II by DSM-IV criteria) recorded mood daily using ChronoRecord software (30,348 total days, mean 150 days). Episodes of hypomania and days of hypomania outside of episodes were determined.
RESULTS: Decreasing the minimum duration criterion for an episode of hypomania from 4 to 2 days doubled the mean percent of days in a hypomanic episode for each patient (4% to 8%), doubled the number of patients with a hypomanic episode (44 to 96) and increased the number of hypomanic episodes for all patients about three-fold (129 to 404). With a minimum episode length of 4 days, bipolar I patients were more likely to report hypomania outside episodes than bipolar II patients (p=0.010), but with a length of 2 or 3 days there was no significant difference in the distribution of hypomania outside of episodes by diagnosis. With a 2-day length, about one-third (36%) of hypomania remained outside of an episode.
LIMITATIONS: Self-reported data, computer access, relatively short length, fewer bipolar II than bipolar I patients.
CONCLUSION: As the minimum length for an episode of hypomania decreases, there was a large increase in both the number of episodes and number of patients with episodes. One-day hypomania outside of episodes occurs frequently in both bipolar I and bipolar II disorder.
This prospective, longitudinal study compared the frequency and pattern of mood changes between outpatients receiving usual care for bipolar disorder who were either taking or not taking antidepressants. One hundred and eighty-two patients with bipolar disorder self-reported mood and psychiatric medications for 4 months using a computerized system (ChronoRecord) and returned 22,626 days of data. One hundred and four patients took antidepressants, 78 did not. Of the antidepressants taken, 95% were selective serotonin or norepinephrine reuptake inhibitors, or second-generation antidepressants. Of the patients taking an antidepressant, 91.3% were concurrently taking a mood stabilizer. The use of antidepressants did not influence the daily rate of switching from depression to mania or the rate of rapid cycling, independent of diagnosis of bipolar I or II. The primary difference in mood pattern was the time spent normal or depressed. Patients taking antidepressants frequently remained in a subsyndromal depression. In this naturalistic study using self-reported data, patients with bipolar disorder who were taking antidepressants--overwhelmingly not tricyclics and with a concurrent mood stabilizer--did not experience an increase in the rate of switches to mania or rapid cycling compared to those not taking antidepressants. Antidepressants had little impact on the mood patterns of bipolar patients taking mood stabilizers.
OBJECTIVE: To assess new treatment options for bipolar disorders.
METHOD: Controlled studies of new treatments for bipolar disorders were identified by computerized searches and reviews of scientific meeting proceedings, and were compiled by drug category.
RESULTS: Two main categories of medications, newer anticonvulsants and newer antipsychotics, are yielding emerging new treatment options for bipolar disorders. Newer anticonvulsants have diverse psychotropic profiles, and although not generally effective for acute mania, may have utility for other aspects of bipolar disorders (e.g. lamotrigine for maintenance or acute bipolar depression), or for comorbid conditions (e.g. gabapentin for anxiety or pain, topiramate for obesity, bulimia, alcohol dependence, or migraine, and zonisamide for obesity). In contrast, newer antipsychotics generally appear effective for acute mania, and some may ultimately prove effective in acute depression (e.g. olanzapine combined with fluoxetine, quetiapine) and maintenance (e.g. olanzapine).
CONCLUSION: Emerging research is yielding new treatment options for bipolar disorders and comorbid conditions.
Lamotrigine therapy in treatment-resistant menstrually-related rapid cycling bipolar disorder: a case report
AIMS/OBJECTIVES: To evaluate lamotrigine in a woman with a 30-year history of treatment-resistant menstrually-entrained rapid cycling bipolar II disorder with follicular phase depressive and luteal phase mood elevation symptoms.
METHODS: Lamotrigine was started at 5 mg/day and gradually increased up to 300 mg/day, while venlafaxine was tapered gradually and discontinued, and divalproex sodium 500 mg/day and levothyroxine 175 mcgm/day were continued. Daily self-reported mood ratings were obtained from the patient, using ChronoRecord software.
RESULTS: As lamotrigine was increased gradually, mood cycle amplitude attenuated. There was notable decrease in the severity and duration of depressive symptoms specifically during the follicular phase of the menstrual cycle. At the time of submission of this paper, the subject had remained euthymic for a total of 12 months.
CONCLUSION: This case suggests the potential utility of lamotrigine in treatment-resistant menstrually-related rapid cycling bipolar disorder, and raises the possibility that lamotrigine might be able to treat pathological entrainment of mood with the menstrual cycle. Both of these issues merit systematic assessment.
This issue brief provides a brief history of Mindfulness-Based Stress Reduction (MBSR) followed by a focus on Mindfulness-Based Cognitive Therapy (MBCT). An overview and literature review of MBCT describes the emergence of MBCT as an intervention addressing depression. This Issue Brief concludes with recent findings that call for further MBCT research in the areas of anxiety and addiction relapse.
Impact of risk/needs assessment on juvenile probation officers' decision making: Importance of implementation
The adoption of risk assessment tools has increased in popularity in the juvenile justice system due, in part, to recommendations by the Juvenile Justice Delinquency Prevention Act (JJDPA). However, very little is known about whether adoption of these tools actually effectuates change in the way young offenders are handled. Qualitative and quantitative data were gathered from 111 juvenile probation officers (JPOs) from six probation offices before and twice after standardized, rigorous implementation of the Structured Assessment of Violence Risk for Youth (SAVRY) or the Youth Level of Service/Case Management Inventory (YLS/CMI). The purpose of this study was to examine JPOs' changes in attitudes and case management decisions following implementation of a risk/needs assessment (RNA) tool. There was a significant reduction in JPOs' perceptions of the proportion of young offenders who would reoffend. There were many shifts in JPOs' decision-making to be more consistent with Risk-Need-Responsivity practices, such as (a) making service referrals based on the fit between youths' criminogenic needs and services, and (b) assigning levels of supervision based on youths' level of risk. There was a shift in attention to more evidence-based dynamic risk factors. These changes occurred regardless of which RNA tool was used. Juvenile justice agencies are encouraged to adopt an evidence-based RNA tool using a sound implementation model in order to meet the objectives of the JJDPA and RNR practices. Benefits and barriers to adoption of RNA tools by juvenile probation departments are discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Categories of Relations Between Stimuli: Foundations for Transitive Inference and Other Emergent Behavior
Recently, Vigo and Allen (2009) proposed a view of transitive inference as categorization that depends only on discriminative performances, similarity judgments, and the formation of categories of which non-human animals and non-verbal humans are capable. Rather than involving language based statements of premises, a network of simple discriminations provides the prerequisites for the emergence of new discriminations involving the transitive relations among stimuli. This view is illustrated briefly here and considered in the broader contexts of two experimental situations of interest to behavior analysts: repeated discrimination reversal training and symmetry in pigeons.
Zinc-finger nucleases (ZFNs) have been used for genome engineering in a wide variety of organisms; however, it remains challenging to design effective ZFNs for many genomic sequences using publicly available zinc-finger modules. This limitation is in part because of potential finger-finger incompatibility generated on assembly of modules into zinc-finger arrays (ZFAs). Herein, we describe the validation of a new set of two-finger modules that can be used for building ZFAs via conventional assembly methods or a new strategy-finger stitching-that increases the diversity of genomic sequences targetable by ZFNs. Instead of assembling ZFAs based on units of the zinc-finger structural domain, our finger stitching method uses units that span the finger-finger interface to ensure compatibility of neighbouring recognition helices. We tested this approach by generating and characterizing eight ZFAs, and we found their DNA-binding specificities reflected the specificities of the component modules used in their construction. Four pairs of ZFNs incorporating these ZFAs generated targeted lesions in vivo, demonstrating that stitching yields ZFAs with robust recognition properties.
The regulated response of endothelial cells to signals in their environment is not only critical for the de novo formation of primordial vascular networks during early development (ie, vasculogenesis), but is also required for the subsequent growth and remodeling of new blood vessels from preexisting ones (ie, angiogenesis). Vascular endothelial growth factors (Vegfs) and their endothelial cell-specific receptors play a crucial role in nearly all aspects of blood vessel growth. How the outputs from these pathways affect and coordinate endothelial behavior is an area of intense research. Recently, numerous studies have highlighted roles for microRNAs in modulating Vegf signaling output in several different contexts. In this review, we will provide an overview of how small RNAs regulate multiple aspects of the Vegf signaling pathway. In particular, we highlight areas where identification of microRNAs and their targets has provided new insight into the role of downstream effectors in modulating Vegf output during development. As Vegf plays a broad role in multiple aspects of endothelial biology and has become a target for therapeutic manipulation of pathological blood vessel growth, microRNAs that affect Vegf signaling output will undoubtedly be major targets of clinical value.
GABP transcription factor is required for development of chronic myelogenous leukemia via its control of PRKD2
Hematopoietic stem cells (HSCs) are the source of all blood lineages, and HSCs must balance quiescence, self-renewal, and differentiation to meet lifelong needs for blood cell development. Transformation of HSCs by the breakpoint cluster region-ABL tyrosine kinase (BCR-ABL) oncogene causes chronic myelogenous leukemia (CML). The E-twenty six (ets) transcription factor GA binding protein (GABP) is a tetrameric transcription factor complex that contains GABPalpha and GABPbeta proteins. Deletion in bone marrow of Gabpa, the gene that encodes the DNA-binding component, caused cell cycle arrest in HSCs and profound loss of hematopoietic progenitor cells. Loss of Gabpalpha prevented development of CML, although mice continued to generate BCR-ABL-expressing Gabpalpha-null cells for months that were serially transplantable and contributed to all lineages in secondary recipients. A bioinformatic screen identified the serine-threonine kinase protein kinase D2 (PRKD2) as a potential effector of GABP in HSCs. Prkd2 expression was markedly reduced in Gabpalpha-null HSCs and progenitor cells. Reduced expression of PRKD2 or pharmacologic inhibition decreased cell cycling, and PRKD2 rescued growth of Gabpalpha-null BCR-ABL-expressing cells. Thus, GABP is required for HSC cell cycle entry and CML development through its control of PRKD2. This offers a potential therapeutic target in leukemia.
Methodological challenges of measuring primary care delivery to pediatric medicaid beneficiaries who use community health centers
Efforts to measure quality of care have focused on ambulatory care providers. We examined the performance of community health centers serving children on Medicaid in 3 states. Descriptive analysis showed considerable patient population heterogeneity, and regression analysis demonstrated that variation explained by the assigned provider was small (mean R(2) = 4.3%) compared with the variation explained by patient demographic variables (mean R(2) = 29.9%). The results reinforce the need for caution when one is attributing quality differences to provider performance.
Matrix metalloproteinase proteolysis of the mycobacterial HSP65 protein as a potential source of immunogenic peptides in human tuberculosis
Mycobacterium tuberculosis is the causative agent of human tuberculosis (TB). Mycobacterial secretory protein ESAT-6 induces matrix metalloproteinase (MMP)-9 in epithelial cells neighboring infected macrophages. MMP-9 then enhances recruitment of uninfected macrophages, which contribute to nascent granuloma maturation and bacterial growth. Disruption of MMP-9 function attenuates granuloma formation and bacterial growth. The abundant mycobacterial 65 kDa heat shock protein (HSP65) chaperone is the major target for the immune response and a critical component in M. tuberculosis adhesion to macrophages. We hypothesized that HSP65 is susceptible to MMP-9 proteolysis and that the resulting HSP65 immunogenic peptides affect host adaptive immunity. To identify MMPs that cleave HSP65, we used MMP-2 and MMP-9 gelatinases, the simple hemopexin domain MMP-8, membrane-associated MMP-14, MMP-15, MMP-16 and MMP-24, and glycosylphosphatidylinositol-linked MMP-17 and MMP-25. We determined both the relative cleavage efficiency of MMPs against the HSP65 substrate and the peptide sequence of the cleavage sites. Cleavage of the unstructured PAGHG474L C-terminal region initiates the degradation of HSP65 by MMPs. This initial cleavage destroys the substrate-binding capacity of the HSP65 chaperone. Multiple additional cleavages of the unfolded HSP65 then follow. MMP-2, MMP-8, MMP-14, MMP-15 and MMP-16, in addition to MMP-9, generate the known highly immunogenic N-terminal peptide of HSP65. Based on our biochemical data, we now suspect that MMP proteolysis of HSP65 in vivo, including MMP-9 proteolysis, also results in the abundant generation of the N-terminal immunogenic peptide and that this peptide, in addition to intact HSP65, contributes to the complex immunomodulatory interplay in the course of TB infection.
Genetic association of GABA-A receptor alpha-2 and mu opioid receptor with cocaine cue-reactivity: evidence for inhibitory synaptic neurotransmission involvement in cocaine dependence
BACKGROUND: This pilot feasibility study examined the role of genetics in laboratory-induced cocaine craving.
METHODS: Thirty-four African American, cocaine-depend- ent male subjects underwent a baseline assessment, cue-exposure session, and genetic analysis. Subjects were classified as either cue-reactive or nonreactive.
RESULTS: Among single nucleotide polymorphism markers in 13 candidate genes examined for association with cocaine cue-reactivity, two were statistically significant: GABRA2 (coding for GABA-A receptor alpha-2 subunit; rs11503014, nominal p= .001) and OPRM1 (coding for mu opioid receptor; rs2236256, nominal p= .03).
CONCLUSIONS: These pilot results suggest that cocaine craving shows variability among cocaine-dependent subjects, and that GABRA2 and OPRM1 polymorphisms have differential influences on cocaine cue-reactivity, warranting studies in future research.
Quality matters! Differences between expressive and receptive non-verbal communication skills in adolescents with ASD
We analyzed several studies of non-verbal communication (prosody and facial expressions) completed in our lab and conducted a secondary analysis to compare performance on receptive vs. expressive tasks by adolescents with ASD and their typically developing peers. Results show a significant between-group difference for the aggregate score of expressive tasks, but not for the aggregate score of receptive tasks. There was also a significant within-group difference among individuals with ASD for expressive vs. receptive performance. Our data indicate that adolescents with ASD can achieve receptive accuracy in non-verbal communication, but show significant qualitative deficits in expressive skills across a range of tasks, which may have a significant negative impact on their success as social communicators.
Comparison of putative intermediate phenotypes in schizophrenia patients with and without obsessive-compulsive disorder: examining evidence for the schizo-obsessive subtype
Obsessive-compulsive symptoms or obsessive-compulsive disorder (OCD) is estimated to occur in up to 30% of patients with schizophrenia. Whether this subgroup of patients is cognitively, affectively, or physiologically distinct remains unclear. 204 schizophrenia patients, 15 who also met criteria for a diagnosis of OCD, and 147 healthy controls were examined on several intermediate phenotypes. The patient groups did not differ from each other except that the co-morbid group exhibited an elevated rate of eye-tracking dysfunction. Results suggest that OCD-co-morbid patients did not comprise a distinct subgroup based on the measures studied here, although systematic assessment of larger cohorts is warranted.
In the past 30 years, the consumer/survivor movement has been developing a consensus national advocacy voice. This chapter reviews three important components in the development of this strong and unified national consumer/ survivor Voice: (a) A consensus by the movement that recovery, wellness, and complete community integration are attainable goals for persons labeled with mental illness in contrast to the traditional negative prognosis of maintenance during a life-long disability; (b) Training programs in advocacy designed and carried out by consumer/survivors, such as Finding Our Voice; (c) Building the National Coalition of Mental Health Consumer/Survivor Organizations, which amplifies the voice of consumer/survivors at the state and federal level.
This chapter contains sections titled: Politics of Diagnosis; Politics of Therapy; Politics of Evidence; Politics of Public Education; Politics of Research and Publication: Influence of the Pharmaceutical Companies; Need for Recovery Research; How to Improve Research and Education in Mental Health.
This chapter contains sections titled: My personal recovery; Research evidence of recovery; Recovery as a movement; Empowerment model of development and recovery; Recovery/independent living; Applying the principles of recovery to clinical care; Consumer-run alternatives to hospitalization; Eight reasons for using a recovery approach in clinical practice.