Lawrence Amsel

Can biological tests assist prediction of suicide in mood disorders

Predicting suicide is difficult due to its low base-rate and the limited specificity of clinical predictors. Prospective biological studies suggest that dysfunctions in the serotonergic system and hypothalamic-pituitary-adrenal axis have some predictive power for completed suicide in mood disorders. A prediction model that incorporates biological testing to increase specificity and sensitivity of prediction of suicide is of potential clinical value. Meta-analyses of prospective biological studies of suicide and cerebrospinal fluid 5-hydroxyindoleacetic acid (CSF 5-HIAA) and suicide and the dexamethasone suppression test (DST) in mood disorders using the penalized quasi-likelihood (PQL) and bootstrap method yield odds ratios for prediction of suicide of 4.48 and 4.65 respectively. Two combinatory prediction models, the first requiring positive results on more than one test, and the second requiring a positive result on either one of two tests, were tested to assess their sensitivity, specificity, and predictive power using biological data from published and unpublished studies. The prediction model that requires both DST and CSF 5-HIAA tests to be positive results in 37.5% sensitivity, 88% specificity, and has a positive predictive value of 23%. The prediction model that requires either DST or CSF 5-HIAA tests to be positive results in 87.5% sensitivity, 28% specificity, and has a positive predictive value of 10%. Thus, models attempting to predict a lethal outcome that is uncommon perform very differently making model choice of major importance. Further work on refining biological predictors and integration with clinical predictors is needed to optimize a model to predict suicide in the clinic.

Combined prolonged exposure therapy and paroxetine for PTSD related to the World Trade Center attack: a randomized controlled trial.

OBJECTIVE Selective serotonin reuptake inhibitors (SSRIs) are often recommended in combination with established cognitive-behavioral therapies (CBTs) for posttraumatic stress disorder (PTSD), but combined initial treatment of PTSD has not been studied under controlled conditions. There are also few studies of either SSRIs or CBT in treating PTSD related to terrorism. The authors compared prolonged exposure therapy (a CBT) plus paroxetine (an SSRI) with prolonged exposure plus placebo in the treatment of terrorism-related PTSD. METHOD Adult survivors of the World Trade Center attack of September 11, 2001, with PTSD were randomly assigned to 10 weeks of treatment with prolonged exposure (10 sessions) plus paroxetine (N=19) or prolonged exposure plus placebo (N=18). After week 10, patients discontinued prolonged exposure and were offered 12 additional weeks of continued randomized treatment. RESULTS Patients treated with prolonged exposure plus paroxetine experienced significantly greater improvement in PTSD symptoms (incidence rate ratio=0.50, 95% CI=0.30-0.85) and remission status (odds ratio=12.6, 95% CI=1.23-129) during 10 weeks of combined treatment than patients treated with prolonged exposure plus placebo. Response rate and quality of life were also significantly more improved with combined treatment. The subset of patients who continued randomized treatment for 12 additional weeks showed no group differences. CONCLUSIONS Initial treatment with paroxetine plus prolonged exposure was more efficacious than prolonged exposure plus placebo for PTSD related to the World Trade Center attack. Combined treatment medication and prolonged exposure therapy deserves further study in larger samples with diverse forms of PTSD and over longer follow-up periods.

Training therapists to treat the psychological consequences of terrorism : Disseminating psychotherapy research and researching psychotherapy dissemination

Abstract In the wake of 9/11, the mental health community began to develop a model for recovery and preparedness. A public information campaign regarding the psychological consequences of terrorism was launched, and it succeeded in reducing the stigma of utilizing mental health services. However, as this campaign began to succeed, it became clear that most clinicians in the community had little training in evidence-based assessment and treatment procedures for the psychological sequelae of terrorism. This article describes the development, delivery, and initial assessment of one attempt to correct this problem by broadly disseminating an effective treatment for Post Traumatic Stress Disorder (PTSD). Using models of behavior change, we were able to study trainee attitudes and the training process in ways that will help improve training effectiveness beyond what traditional Continuing Professional Education (CPE) has been able to do.

Does a Study Focused on Trauma Encourage Patients With Psychotic Symptoms to Seek Treatment

OBJECTIVE This study explored, in a randomized trial of psychotherapies for posttraumatic stress disorder (PTSD), why a surprisingly high percentage of study applicants presented with psychotic symptoms and what clinical implications this finding might prompt. METHODS Raters reviewed the records of applicants who completed an initial psychiatric interview and compared those who had psychotic symptoms with all other study-eligible participants and with those who ultimately were enrolled in the study. RESULTS Of 223 consecutively evaluated individuals who applied for study entry, 38 (17%) were found ineligible because of psychotic symptoms. These individuals were more likely to be male and to have suffered child abuse, and they had taken a greater number of lifetime medications than study-eligible applicants. Most individuals with psychotic symptoms met DSM-IV criteria for PTSD. CONCLUSIONS A trauma-informed framework might be a helpful part of a comprehensive treatment plan for some individuals with psychotic symptoms, possibly leading to greater treatment engagement and more positive outcomes.

Brain activity classifies adolescents with and without a familial history of substance use disorders

We aimed to uncover differences in brain circuits of adolescents with parental positive or negative histories of substance use disorders (SUD), when performing a task that elicits emotional conflict, testing whether the brain circuits could serve as endophenotype markers to distinguish these adolescents. We acquired functional magnetic resonance imaging data from 11 adolescents with a positive familial history of SUD (FH+ group) and seven adolescents with a negative familial history of SUD (FH− group) when performing an emotional stroop task. We extracted brain features from the conflict-related contrast images in group level analyses and granger causality indices (GCIs) that measure the causal interactions among regions. Support vector machine (SVM) was applied to classify the FH+ and FH− adolescents. Adolescents with FH+ showed greater activity and weaker connectivity related to emotional conflict, decision making and reward system including anterior cingulate cortex (ACC), prefrontal cortex (PFC), and ventral tegmental area (VTA). High classification accuracies were achieved with leave-one-out cross validation (89.75% for the maximum conflict, 96.71% when combining maximum conflict and general conflict contrast, 97.28% when combining activity of the two contrasts and GCIs). Individual contributions of the brain features to the classification were further investigated, indicating that activation in PFC, ACC, VTA and effective connectivity from PFC to ACC play the most important roles. We concluded that fundamental differences of neural substrates underlying cognitive behaviors of adolescents with parental positive or negative histories of SUD provide new insight into potential neurobiological mechanisms contributing to the elevated risk of FH+ individuals for developing SUD.

The Mental Health of Children and Adolescents Exposed to 9/11: Lessons Learned and Still to be Learned

The mental health effects of 9/11 on children and adolescents have often been viewed through the same lens as the effects on adults. Yet, children differ from adults in multiple ways and have specific vulnerabilities and dependencies that can moderate the impact of exposure to disasters. This chapter provides an overview of the studies that investigated psychopathological outcomes attributed to the attack on the World Trade Center among youth ages 0–18 years on 9/11 in order to identify which categories of youth were most affected, how they were affected, and which risk factors contributed to these outcomes. The chapter considers the effects of 9/11 not only on those in close proximity to the World Trade Center but also those who were indirectly exposed through their families, as well as those exposed through the media. This body of research is critically evaluated, evaluating which lessons have been learned, what has been missed, and how we might better protect our youth in the future, in the face of mass trauma.