Paul D. Kirwin

Limited efficacy of ketoconazole in treatment-refractory major depression.

The authors examined the efficacy of ketoconazole in 16 adults with treatment-refractory major depressive disorder. Subjects participated in a 6-week, double-blind, placebo-controlled trial. Assessments of mood were made using the Hamilton Rating Scale for Depression (HAM-D), the Beck Depression Inventory (BDI), and the Clinical Global Impression Scale (CGI). Results showed that none of eight patients randomly assigned to receive placebo and two of eight patients randomly assigned to receive ketoconazole met criteria for response. As a group, patients assigned to receive ketoconazole showed no significant reductions in HAM-D, BDI, or CGI scores during the 6-week trial compared with those receiving placebo. These findings suggest a limited efficacy for ketoconazole in patients with treatment-refractory major depression.

Programs for Developing the Pipeline of Early-Career Geriatric Mental Health Researchers: Outcomes and Implications for Other Fields

This report summarizes the findings and recommendations of an expert consensus workgroup that addressed the endangered pipeline of geriatric mental health (GMH) researchers. The workgroup was convened at the Summit on Challenges in Recruitment, Retention, and Career Development in Geriatric Mental Health Research in late 2007. Major identified challenges included attracting and developing early-career investigators into the field of GMH research; a shortfall of geriatric clinical providers and researchers; a disproportionate lack of minority researchers; inadequate mentoring and career development resources; and the loss of promising researchers during the vulnerable period of transition from research training to independent research funding. The field of GMH research has been at the forefront of developing successful programs that address these issues while spanning the spectrum of research career development. These programs serve as a model for other fields and disciplines. Core elements of these multicomponent programs include summer internships to foster early interest in GMH research (Summer Training on Aging Research Topics–Mental Health Program), research sponsorships aimed at recruitment into the field of geriatric psychiatry (Stepping Stones), research training institutes for early career development (Summer Research Institute in Geriatric Psychiatry), mentored intensive programs on developing and obtaining a first research grant (Advanced Research Institute in Geriatric Psychiatry), targeted development of minority researchers (Institute for Research Minority Training on Mental Health and Aging), and a Web-based clearinghouse of mentoring seminars and resources (MedEdMentoring.org). This report discusses implications of and principles for disseminating these programs, including examples of replications in fields besides GMH research.

Subsyndromal depression among older adults in the USA: prevalence, comorbidity, and risk for new-onset psychiatric disorders in late life

Population‐based data are lacking on the prevalence and comorbidity of subsyndromal depression (SSD) and its associated risk for incident psychiatric disorders in older adults.

AAGP position statement: disaster preparedness for older Americans: critical issues for the preservation of mental health.

The Disaster Preparedness Task Force of the American Association for Geriatric Psychiatry was formed after Hurricane Katrina devastated New Orleans to identify and address needs of the elderly after the disaster that led to excess health disability and markedly increased rates of hopelessness, suicidality, serious mental illness (reported to exceed 60% from baseline levels), and cognitive impairment. Substance Abuse and Mental Health Services Administration (SAMHSA) outlines risk groups which fail to address later effects from chronic stress and loss and disruption of social support networks. Range of interventions recommended for Preparation, Early Response, and Late Response reviewed in the report were not applied to elderly for a variety of reasons. It was evident that addressing the needs of elderly will not be made without a stronger mandate to do so from major governmental agencies (Federal Emergency Management Agency [FEMA] and SAMHSA). The recommendation to designate frail elderly and dementia patients as a particularly high-risk group and a list of specific recommendations for research and service and clinical reference list are provided.

Successful Aging Among Older Veterans in the United States

OBJECTIVE To develop a unidimensional latent model of successful aging and to evaluate sociodemographic, medical, psychiatric, and psychosocial correlates of this construct in a nationally representative sample of older veterans in the United States. METHODS Data were analyzed from a cross-sectional web survey of 2,025 U.S. veterans aged 60 to 96 years who participated in the National Health and Resilience in Veterans Study. Self-report measures of sociodemographics; subjective physical, mental, and cognitive functioning; and psychosocial characteristics were used. Confirmatory factor analysis was used to construct a unidimensional latent factor of successful aging. Correlates of scores on this factor were then evaluated. RESULTS Most older veterans (82.1%) rated themselves as aging successfully. A unidimensional latent factor composed of seven measures of self-rated successful aging, quality of life, and physical, mental, cognitive, and social functioning provided a good fit to the data. Physical health difficulties (β = -0.39) and current psychological distress (β = -0.33) were most strongly negatively related to scores on this latent factor of successful aging, while protective psychosocial characteristics (β = 0.22), most notably resilience, gratitude, and purpose in life, were most strongly positively related to these scores. Additional positive predictors of successful aging included White, non-Hispanic race, being married or living with partner, perceiving a positive effect of the military on ones life, active lifestyle, positive expectations regarding aging, and conscientiousness; additional negative predictors included substance abuse history. CONCLUSION Results of this study provide a dimensional approach to characterizing components and correlates of successful aging in older veterans. Interventions and policy initiatives designed to mitigate physical health difficulties and psychological distress and to enhance protective psychosocial characteristics such as resilience, gratitude, and purpose in life may help promote successful aging in this population.

Proposed Geriatric Psychiatry Core Competencies for Subspecialty Training

The authors present and discuss the theoretical and practical development of proposed core competencies for subspecialty training and certification in geriatric psychiatry as required by the Accreditation Council For Graduate Medical Education (ACGME) and the American Board of Psychiatry and Neurology (ABPN). Changes were derived from a concern that graduate medical education programs must do a better job of ensuring that residents completing their training are competent to practice medicine and adequately prepared to practice in a rapidly changing healthcare environment. Between July 2006 and June 2011, programs will be expected to focus on data-driven measures, both internal and national, for resident and education-program performance. After July 2011, programs will begin to focus on identifying and developing educational centers of excellence.

Increased cerebrospinal fluid corticotropin-releasing factor concentrations during tryptophan depletion in healthy adults

BACKGROUND Brain serotonin neurotransmission and hypothalamic-pituitary-adrenal axis function are implicated in the pathophysiology of depression, and these systems interact in a reciprocal modulatory fashion. This study examined the effect of tryptophan depletion, which acutely reduces brain serotonin concentrations, on serial cerebrospinal fluid concentrations of corticotropin-releasing factor in healthy humans. METHODS Five subjects completed a standard tryptophan depletion protocol, and four subjects participated in a comparison condition. Subjects underwent continuous sampling of cerebrospinal fluid via lumbar peristaltic pump. Concentrations of cerebrospinal fluid corticotropin-releasing factor were measured by radioimmunoassay. RESULTS No mood changes were observed in either group. Tryptophan-depleted subjects exhibited significantly greater increases in corticotropin-releasing factor concentrations over time than subjects in the comparison condition. CONCLUSIONS These findings highlight the potential importance of corticotropin-releasing factor and serotonin interactions and suggest that activation of corticotropin-releasing-factor-containing neurons could play a role in the emergence of mood symptoms following tryptophan depletion in vulnerable individuals.

Increased Risk Among Older Veterans of Prescribing Psychotropic Medication in the Absence of Psychiatric Diagnoses

OBJECTIVE This study uses Veterans Health Administration (VHA) pharmacy and encounter claims to evaluate the use of psychotropic medications without a psychiatric diagnosis across age groups. METHODS National VHA administrative data for fiscal year 2010 (FY2010) were used to identify all veterans who filled a prescription for at least one psychotropic medication from VHA (N = 1.85 million). Bivariate and multivariate analyses were used to compare the proportion of these veterans without any psychiatric diagnosis, across age groups, adjusting for possible medical indications. Analyses were repeated for six different classes of psychotropic medications and comparing mental health utilizers and non-mental health utilizers. Comparisons were made to prescribing of HIV and diabetes medications without an indicated diagnosis. RESULTS Of all VHA patients prescribed a psychotropic medication in FY2010, 30% had no psychiatric diagnosis, with highest proportions among veterans ages 65-85. This practice was most frequent among nonmental health utilizers and far more prevalent for psychotropic medications than for HIV or diabetes medications. Logistic regression analysis found that age greater than 65 was the strongest predictor of being prescribed a psychotropic without a psychiatric diagnosis. Adjustment for possible medical use of psychotropics and overall medical comorbidity did not substantially alter these trends. CONCLUSION Older veterans, especially those not using specialty mental healthcare, are more likely to be prescribed psychotropic medications in the absence of a psychiatric diagnosis, perhaps representing unnecessary use, under-diagnosis of mental illness, or incomplete documentation.

ASSESSMENT OF DIURNAL VARIATION OF CEREBROSPINAL FLUID TRYPTOPHAN AND 5-HYDROXYINDOLEACETIC ACID IN HEALTHY HUMAN FEMALES

The role of serotonin (5-HT) in the pathogenesis and treatment of major neuropsychiatric disorders, including mood and anxiety disorders, continues to be the subject of extensive research. Previous studies examining central 5-HT functioning measured cerebrospinal fluid (CSF) levels of 5-hydroxyindoleacetic acid (5-HIAA) by using single or multiple lumbar punctures. A number of investigators have demonstrated the feasibility of continuous CSF sampling via an indwelling lumbar catheter to study CSF neurochemistry in healthy subjects and patients with neuropsychiatric illness. Four healthy female volunteers, aged 21-34 years, underwent continuous CSF sampling. CSF was collected at a constant rate of 1 ml every 10 minutes over a 30-hour period, with levels of tryptophan (TRP) and 5-HIAA measured every hour. Plasma was also obtained hourly for TRP determination. The results of this study indicate that CSF 5-HIAA, CSF TRP, and plasma TRP levels showed variation over time, but failed to show diurnal fluctuation. Intra-individual coefficients of variation determined for CSF 5-HIAA, CSF TRP, and plasma TRP ranged from 9.2 to 14.9%, 8.8 to 14.6%, and 14.7 to 19.0%, respectively. Continuous CSF sampling is safe and feasible in humans, and may prove useful for studies of central 5-HT neurotransmission in neuropsychiatric illness.

Psychological resilience in U.S. military veterans: A 2-year, nationally representative prospective cohort study

Although many cross-sectional studies have examined the correlates of psychological resilience in U.S. military veterans, few longitudinal studies have identified long-term predictors of resilience in this population. The current prospective cohort study utilized data from a nationally representative sample of 2157 U.S. military veterans who completed web-based surveys in two waves (2011 and 2013) as part of the National Health and Resilience in Veterans Study (NHRVS). Cluster analysis of cumulative lifetime exposure to potentially traumatic events and Wave 2 measures of current symptoms of posttraumatic stress, major depressive, and generalized anxiety disorders was performed to characterize different profiles of current trauma-related psychological symptoms. Different profiles were compared with respect to sociodemographic, clinical, and psychosocial characteristics. A three-group cluster analysis revealed a Control group with low lifetime trauma exposure and low current psychological distress (59.5%), a Resilient group with high lifetime trauma and low current distress (27.4%), and a Distressed group with both high trauma exposure and current distress symptoms (13.1%). These results suggest that the majority of trauma-exposed veterans (67.7%) are psychologically resilient. Compared with the Distressed group, the Resilient group was younger, more likely to be Caucasian, and scored lower on measures of physical health difficulties, past psychiatric history, and substance abuse. Higher levels of emotional stability, extraversion, dispositional gratitude, purpose in life, and altruism, and lower levels of openness to experiences predicted resilient status. Prevention and treatment efforts designed to enhance modifiable factors such as gratitude, sense of purpose, and altruism may help promote resilience in highly trauma-exposed veterans.