John Hennen

Severity of reported childhood sexual abuse and its relationship to severity of borderline psychopathology and psychosocial impairment among borderline inpatients.

This study has two purposes. The first purpose is to describe the severity of sexual abuse reported by a well-defined sample of borderline inpatients. The second purpose is to determine the relationship between the severity of reported childhood sexual abuse, other forms of childhood abuse, and childhood neglect and the severity of borderline symptoms and psychosocial impairment. Two semistructured interviews of demonstrated reliability were used to assess the severity of adverse childhood experiences reported by 290 borderline inpatients. It was found that more than 50% of sexually abused borderline patients reported being abused both in childhood and in adolescence, on at least a weekly basis, for a minimum of 1 year, by a parent or other person well known to the patient, and by two or more perpetrators. More than 50% also reported that their abuse involved at least one form of penetration and the use of force or violence. Using multiple regression modeling and controlling for age, gender, and race, it was found that the severity of reported childhood sexual abuse was significantly related to the severity of symptoms in all four core sectors of borderline psychopathology (affect, cognition, impulsivity, and disturbed interpersonal relationships), the overall severity of borderline personality disorder, and the overall severity of psychosocial impairment. It was also found that the severity of childhood neglect was significantly related to five of the 10 factors studied, including the overall severity of borderline personality disorder, and that the severity of other forms of childhood abuse was significantly related to two of these factors, including the severity of psychosocial impairment. Taken together, the results of this study suggest that the majority of sexually abused borderline inpatients may have been severely abused. They also suggest that the severity of childhood sexual abuse, other forms of childhood abuse, and childhood neglect may all play a role in the symptomatic severity and psychosocial impairment characteristic of borderline personality disorder.

Aspirin in the Treatment of Acute Myocardial Infarction in Elderly Medicare Beneficiaries Patterns of Use and Outcomes

BACKGROUND Although aspirin is an effective, inexpensive, and safe treatment of acute myocardial infarction, the frequency of use of aspirin in actual medical practice is not known. Elderly patients, a group with low rates of utilization of effective therapies such as thrombolytic therapy, also may be at risk of not receiving aspirin for acute myocardial infarction. To address this issue, we sought to determine the current pattern of aspirin use and to assess its effectiveness in a large, population-based sample of elderly patients hospitalized with acute myocardial infarction. METHODS AND RESULTS As part of the Cooperative Cardiovascular Project Pilot, a Health Care Financing Administration initiative to improve quality of care for Medicare beneficiaries, we abstracted hospital medical records of Medicare beneficiaries who were hospitalized in Alabama, Connecticut, Iowa, or Wisconsin from June 1992 through February 1993. Among the 10,018 patients > or = 65 years old who had no absolute contraindications to aspirin, 6140 patients (61%) received aspirin within the first 2 days of hospitalization. Patients who were older, had more comorbidity, presented without chest pain, and had high-risk characteristics such as heart failure and shock were less likely to receive aspirin. The use of aspirin was significantly associated with a lower mortality (OR, 0.78; 95% CI, 0.70 to 0.89) after adjustment for potential confounders. CONCLUSIONS About one third of elderly patients with acute myocardial infarction who had no contraindications to aspirin therapy did not receive it within the first 2 days of hospitalization. The elderly patients with the highest risk of death were the least likely to receive aspirin. After adjustment for differences between the treatment groups, the use of aspirin was associated with 22% lower odds of 30-day mortality. The increased use of aspirin for patients with acute myocardial infarction is an excellent opportunity to improve the delivery of care to elderly patients.

A DSM-IV Axis I Comorbidity Study of Males (n = 120) With Paraphilias and Paraphilia-Related Disorders

One hundred and twenty consecutively evaluated outpatient males with paraphilias (PAs; n = 88, including 60 sex offenders) and paraphilia-related disorders (PRDs; n = 32) were systematically assessed for certain developmental variables and DSM-IV-defined Axis I comorbidity. In comparison with the PRDs, the PA group was statistically significantly more likely to self-report a higher incidence of physical (but not sexual) abuse, fewer years of completed education, a higher prevalence of school-associated learning and behavioral problems, more psychiatric/substance abuse hospitalizations, and increased employment-related disability as well as more lifetime contact with the criminal justice system. In both groups, the most prevalent Axis I disorders were mood disorders (71.6%), especially early onset dysthymic disorder (55%) and major depression (39%). Anxiety disorders (38.3%), especially social phobia (21.6%), and psychoactive substance abuse (40.8%), especially alcohol abuse (30%), were reported as well. Cocaine abuse was statistically significantly associated with PA males (p = .03). There was a statistically significant correlation between the lifetime prevalence of Axis I nonsexual diagnoses and hypersexual diagnoses (PAs and PRDs). The prevalence of retrospectively diagnosed attention deficit hyperactivity disorder (ADHD) was 35.8%, the third most prevalent Axis I disorder. ADHD (p = .01), especially ADHD-combined subtype (p = .009), was statistically significantly associated with PA status. ADHD was statistically significantly associated with conduct disorder, and both of these Axis I disorders were associated with the propensity for multiple PAs and a higher likelihood of incarceration. When the diagnosis of ADHD was controlled, the differences reported above between PAs and PRDs either became statistically nonsignificant or remained as only statistical trends. Thus, ADHD and its associated developmental sequellae and Axis I comorbidities was the single most common nonsexual Axis I diagnosis that statistically significantly distinguished males with socially deviant sexual arousal (PAs) from a nonparaphilic hypersexual comparison group (PRDs). Sex offender paraphiliacs were more likely to be diagnosed with conduct disorder, alcohol abuse, cocaine abuse, and generalized anxiety disorder. The prevalence of any ADHD in the sex offender paraphiliacs was 43.3%, and nearly 25% of offenders were diagnosed with ADHD-combined subtype.

Lower suicide risk with long‐term lithium treatment in major affective illness: a meta‐analysis

Objective: To compare suicide rates with vs. without long‐term lithium treatment in major affective disorders.

Patterns of psychotropic drug prescription for U.S. patients with diagnoses of bipolar disorders.

OBJECTIVE Bipolar disorders are prevalent major illnesses with high rates of morbidity, comorbidity, disability, and mortality. A growing number of psychotropic drugs are used to treat bipolar disorder, often off-label and in untested, complex combinations. METHODS To quantify utilization rates for psychotropic drug classes, this study used the 2002-2003 U.S. national MarketScan research databases to identify 7,760 persons with ICD-9 bipolar disorder subtypes. Survival analysis was used to estimate times until initial monotherapies were augmented, changed, or discontinued. RESULTS The most commonly prescribed first drug class was antidepressants (50% of patients), followed by mood stabilizers (25%: anticonvulsants, 17%, and lithium, 8%), sedatives (15%), and antipsychotics (11%). At study midpoint only 44% of patients were receiving monotherapy. Those receiving monotherapy were ranked by initial drug prescribed and percentage of patients (bipolar I and bipolar II): antidepressants (55% and 65%), lithium (51% and 41%), antipsychotics (32% and 31%), anticonvulsants (28% and 29%), and sedatives (28%, 25%). Median time to adding another psychotropic was 2.5-times less than median time to changing the initial treatment (16.4 compared with 40.9 weeks), and stopping was rare. Median weeks until therapy was changed in any way for 25% of patients was as follows: lithium, 29 weeks; antidepressants, 13; anticonvulsants, 13; antipsychotics, 13; and sedatives, 9. CONCLUSIONS Antidepressants were the first-choice agent twice as often as mood stabilizers. Lithium was sustained longer than monotherapy with other mood stabilizers. Time to augmentation was much shorter than time to change or discontinuation.

Suicidal risk during treatment with clozapine: a meta-analysis.

OBJECTIVE Suicide remains a major cause of premature mortality among patients with schizophrenia. Evidence of reduced suicidal risk with available psychiatric treatments is limited, but emerging data suggest such an effect of clozapine in chronically psychotic patients, leading us to compile the reported evidence. METHOD We searched for published studies with contrasting rates of suicides or attempts by psychotic patients treated with clozapine vs. other agents. RESULTS Among six such studies, random-effects meta-analysis indicated a substantially lower overall risk of suicidal behaviors with clozapine vs. other treatments (risk-ratio 3.3; 95% confidence interval [CI] 1.7-6.3; p<0.0001). For completed suicides, the risk ratio (RR) was 2.9 ([CI 1.5-5.7]; p=0.002). CONCLUSION Long-term treatment with clozapine was associated with three-fold overall reduction of risk of suicidal behaviors. However, available findings are quantitatively inconsistent, well-designed studies remain rare, and the only randomized trial did not find reduced risk of completed suicide. Additional randomized comparisons among modern treatments for psychotic disorders are required to clarify their impact on mortality.

Genetics of Suicide: An Overview

&NA; Risk for suicide may have heritable contributions. Evidence supporting this hypothesis includes strong and consistent findings from more than 20 controlled family studies indicating nearly 5‐fold greater relative risk of suicidal acts among relatives of index cases with suicidal behavior compared to relatives of nonsuicidal controls. Relative risk was greater for completed suicide than for attempts. Contributions of genetic instead of environmental factors are indicated by a higher average concordance for suicidal behavior among co‐twins of suicidal identical twins compared to fraternal twins or to relatives of other suicidal subjects, in at least seven studies. Three studies indicate significantly greater suicidal risk, particularly for completed suicide, among biological versus adoptive relatives of suicidal or mentally ill persons adopted early in life. Molecular genetics studies have searched inconclusively for associations of suicidal behavior with genes mainly for proteins required for central serotonergic neurotransmission. Complex interactions of environmental with heritable risk and protective factors for suicide and psychiatric illnesses or vulnerability traits are suspected, but specific intervening mechanisms remain elusive. Familial or genetic risks for psychiatric factors strongly associated with suicide, such as major affective illnesses and alcohol abuse, as well as impulsive or aggressive traits, have not consistently been separated from suicidal risk itself.

A Randomized Trial of Integrated Group Therapy Versus Group Drug Counseling for Patients With Bipolar Disorder and Substance Dependence

OBJECTIVE Although bipolar disorder and substance use disorder frequently co-occur, there is little information on the effectiveness of behavioral treatment for this population. Integrated group therapy, which addresses the two disorders simultaneously, was compared with group drug counseling, which focuses on substance use. The authors hypothesized that patients receiving integrated group therapy would have fewer days of substance use and fewer weeks ill with bipolar disorder. METHOD A randomized controlled trial compared 20 weeks of integrated group therapy or group drug counseling with 3 months of posttreatment follow-up. Sixty-two patients with bipolar disorder and current substance dependence, treated with mood stabilizers for >or=2 weeks, were randomly assigned to integrated group therapy (N=31) or group drug counseling (N=31). The primary outcome measure was the number of days of substance use. The primary mood outcome was the number of weeks ill with a mood episode. RESULTS Intention-to-treat analysis revealed significantly fewer days of substance use for integrated group therapy patients during treatment and follow-up. Groups were similar in the number of weeks ill with bipolar disorder during treatment and follow-up, although integrated group therapy patients had more depressive and manic symptoms. CONCLUSIONS Integrated group therapy, a new treatment developed specifically for patients with bipolar disorder and substance dependence, appears to be a promising approach to reduce substance use in this population.

Vasomotor symptoms are associated with depression in perimenopausal women seeking primary care.

ObjectiveTo compare the relationship between vasomotor symptoms (hot flushes and night sweats) and depression in perimenopausal women with that in postmenopausal and older premenopausal women. DesignQuestionnaire data assessing current depressive symptoms (Center for Epidemiologic Studies Depression Scale), hot flushes, night sweats, menopausal status, depression history, hormonal therapy use, and demographic characteristics were collected from women aged 40 to 60 years seeking primary care. Multivariable logistic regression models were used to examine the relationship between vasomotor symptoms and depression. ResultsDepression (defined by a Center for Epidemiologic Studies Depression Scale score ≥ 25) was observed in 14.9% of 141 perimenopausal women, 13.9% of 151 postmenopausal women, and 7.6% of 184 older premenopausal women. Recent vasomotor symptoms were reported by 53.9% of perimenopausal women, 43.7% of postmenopausal women, and 20.7% of older premenopausal women. Perimenopausal women with vasomotor symptoms were 4.39 times more likely to be depressed than those without vasomotor symptoms (95% CI, 1.40-13.83), an association that did not change after controlling for depression history. In contrast with perimenopausal women, postmenopausal and older premenopausal women with vasomotor symptoms did not have a significantly greater risk for depression than women of the same menopausal status without vasomotor symptoms (adjusted odds ratios, 1.28 and 1.77; 95% CI, 0.47–3.46 and 0.53–5.89, respectively). ConclusionsHot flushes and night sweats are associated with depression in perimenopausal women. Further investigation is warranted to elucidate the mechanism by which hot flushes may be associated with depression in perimenopausal women and not in postmenopausal or older premenopausal women.

The pain of being borderline: dysphoric states specific to borderline personality disorder.

&NA; The objective of this study was to identify the dysphoric states that best characterize patients meeting criteria for borderline personality disorder and distinguish them from those in patients with other forms of personality disorder. One hundred forty‐six patients with criteria‐defined borderline personality disorder and 34 Axis II controls filled out the Dysphoric Affect Scale, a 50‐item self‐report measure that was designed for this purpose and has good internal consistency and test‐retest reliability. Twenty‐five dysphoric states (mostly affects) were found to be significantly more common among borderline patients than controls but nonspecific to borderline personality disorder. Twenty‐five other dysphoric states (mostly cognitions) were found to be both significantly more common among borderline patients than controls and highly specific to borderline personality disorder. These states tended to fall into one of four clusters: (1) extreme feelings, (2) destructiveness or self‐destructiveness, (3) fragmentation or “identitylessness,” and (4) victimization. In addition, three of the 25 more‐specific states (feeling betrayed, like hurting myself, and completely out of control), when occurring together, were particularly strongly associated with the borderline diagnosis. Equally important, overall mean Dysphoric Affect Scale scores correctly distinguished borderline personality disorder from other personality disorders in 84% of the subjects. Taken together, the results of this study suggest that the subjective pain of borderline patients may be both more pervasive and more multifaceted than previously recognized, and that the overall “amplitude” of this pain may be a particularly good marker for the borderline diagnosis.