Raphael J. Leo

An Upside to Adversity? Moderate Cumulative Lifetime Adversity Is Associated With Resilient Responses in the Face of Controlled Stressors

Despite common findings suggesting that lack of negative life events should be optimal, recent work has revealed a curvilinear pattern, such that some cumulative lifetime adversity is instead associated with optimal well-being. This work, however, is limited in that responses to specific stressors as they occurred were not assessed, thereby precluding investigation of resilience. The current research addressed this critical gap by directly testing the relationship between adversity history and resilience to stressors. Specifically, we used a multimethod approach across two studies to assess responses to controlled laboratory stressors (respectively requiring passive endurance and active instrumental performance). Results revealed hypothesized U-shaped relationships: Relative to a history of either no adversity or nonextreme high adversity, a moderate number of adverse life events was associated with less negative responses to pain and more positive psychophysiological responses while taking a test. These results provide novel evidence in support of adversity-derived propensity for resilience that generalizes across stressors.

Cardiomyopathy associated with clozapine.

Objective To report a case of symptomatic cardiomyopathy induced during treatment with clozapine, an antipsychotic of the dibenzodiazepine class. Case Summary A patient with a long psychiatric history significant for schizophrenia and no prior cardiac history developed dyspnea, malaise, and edema with a low ventricular ejection fraction during clozapine therapy. Discussion The literature concerning cardiorespiratory complications with clozapine therapy is reviewed. Conclusions Cardiorespiratory complications associated with clozapine use are rare. Caution may be warranted in patients treated with other medications, such as benzodiazepines, and in patients with underlying cardiac disease.

A Systematic Review of the Utility of Antidepressant Pharmacotherapy in the Treatment of Vulvodynia Pain

Introduction.  Antidepressants have often been recommended as a potential treatment for the management of vulvodynia. However, review of the evidence supporting this recommendation has not been systematically assessed. Aim.  To evaluate the efficacy of antidepressant pharmacotherapy in the treatment of vulvodynia. Main Outcome Measures.  An assessment of the methodological quality of published reports addressing the utility of antidepressants in the treatment of vulvodynia was undertaken. Several secondary outcomes generated in the existing literature were also examined. Methods.  A comprehensive search of the available literature was conducted. Results.  The search yielded 13 published reports, i.e., 2 randomized controlled trials, 1 quasi-experimental trial, 7 non-experimental studies, and 3 case reports. A number of methodological shortcomings were identified in several of the reports with respect to study design including lack of clear inclusion/exclusion criteria, small sample sizes, lack of comparison groups, insufficient blinding, among others. The vast majority of studies utilized tricyclic antidepressants (TCAs). Evidence supporting the benefits of TCAs studied to date was limited, i.e., based largely upon descriptive reports but unsubstantiated by randomized controlled trials. There were no systematic investigations into the comparative efficacy of different antidepressant classes in the treatment of vulvodynia. Conclusion.  There is insufficient evidence to support the recommendation of antidepressant pharmacotherapy in the treatment of vulvodynia. Although some vulvodynia-afflicted patients derive symptom relief from antidepressants, additional research is required to identify those characteristics that would predict those patients for whom antidepressants are more likely to be effective. Leo RJ and Dewani S. A systematic review of the utility of antidepressant pharmacotherapy in the treatment of vulvodynia pain. J Sex Med 2013;10:2497–2505.INTRODUCTION   Antidepressants have often been recommended as a potential treatment for the management of vulvodynia. However, review of the evidence supporting this recommendation has not been systematically assessed. AIM   To evaluate the efficacy of antidepressant pharmacotherapy in the treatment of vulvodynia. MAIN OUTCOME MEASURES   An assessment of the methodological quality of published reports addressing the utility of antidepressants in the treatment of vulvodynia was undertaken. Several secondary outcomes generated in the existing literature were also examined. METHODS   A comprehensive search of the available literature was conducted. RESULTS   The search yielded 13 published reports, i.e., 2 randomized controlled trials, 1 quasi-experimental trial, 7 non-experimental studies, and 3 case reports. A number of methodological shortcomings were identified in several of the reports with respect to study design including lack of clear inclusion/exclusion criteria, small sample sizes, lack of comparison groups, insufficient blinding, among others. The vast majority of studies utilized tricyclic antidepressants (TCAs). Evidence supporting the benefits of TCAs studied to date was limited, i.e., based largely upon descriptive reports but unsubstantiated by randomized controlled trials. There were no systematic investigations into the comparative efficacy of different antidepressant classes in the treatment of vulvodynia. CONCLUSION   There is insufficient evidence to support the recommendation of antidepressant pharmacotherapy in the treatment of vulvodynia. Although some vulvodynia-afflicted patients derive symptom relief from antidepressants, additional research is required to identify those characteristics that would predict those patients for whom antidepressants are more likely to be effective.

Word intelligibility decrements and the comprehension of time-compressed speech.

The extent to which decreased comprehension of time-compressed messages results from decreased word intelligibility was investigated. Experiment 1, in which 500-word messages were temporally interrupted, demonstrated that when 60% of the signal is deleted, comprehension is reduced even without the temporal limitations of compression. Experiment 2, which employed a backward masking procedure, demonstrated that individually compressed words are less intelligible when presented within the limited time constraints of a compressed message. It was concluded that decreased comprehension of compressed messages is the result of decreased word intelligibility.

Clomipramine treatment of paraphilias in elderly demented patients.

Sexually inappropriate conduct often accompanies the disinhibition associated with dementia and neuropsychologic deficits. Management of these behaviors is problematic and time consuming. We report two cases in which paraphilias responded to treatment with clomipramine. This effect was not due to the sexual side effects of the drug (e.g., decreased ability to sustain an erection or orgasm). Careful monitoring of the elderly patient is required during treatment with clomipramine, particularly with regard to orthostasis, the increased risk of falls, and worsened confusion secondary to the potential risks of anticholinergic delirium and toxicity.

Referral Patterns and Recognition of Depression Among African-American and Caucasian Patients

A retrospective review of psychiatric consultations was conducted for African-American and Caucasian patients for a 2-year period. Reasons for referral, assigned diagnoses, accuracy rates, and discordance and concordance rates were assessed. Referrals for depression comprised 24.6% of all consults for Caucasian and African-American inpatients. Only 40.3% of patients referred for depression were diagnosed with a depressive disorder; 54.4% of patients diagnosed with depressive disorders were referred for other reasons. African-American patients were referred for evaluation of depression and diagnosed with depressive disorders significantly less often than Caucasian patients. No significant differences were obtained between African-Americans and Caucasians in the accuracy rates of patients referred for depression. Discordance and concordance rates for the two groups were comparable. Diagnoses assigned to African-Americans and Caucasians incorrectly referred for depression did not differ significantly. For depressed African-Americans and Caucasians referred for reasons other than depression, the only difference noted was in the referral rates for adjustment of psychotropics. The nonpsychiatric staff fails to recognize depression and often refer depressed patients inappropriately. Depressed patients are primarily referred for suicide assessment and disruptive behaviors. Referrals for depression may be a secondary concern to nonpsychiatric staff. In addition, cultural variables and racial differences between hospital staff and patients may account for the differences in referral patterns. Awareness of the needs of African-American patients is required.

Geropsychiatric consultation for African-American and Caucasian patients

We assessed differences in the referral rates of African-American and Caucasian elderly for geropsychiatric consultation. Reasons for referral, assigned diagnoses, and interventions made were also compared. A retrospective chart review of psychiatric consultations was completed for patients aged 65 years and older for a 2-year period. Significantly more consultations were requested Caucasian elderly (6.2%) than for African-American elderly (3.8%). African-American elderly were referred for evaluation of psychosis significantly more often and for assessment of suicide potential significantly less often than Caucasians. Consultants diagnosed African-American elderly with psychotic disorders, specifically schizophrenia, and dementia significantly more often than Caucasians. Caucasian elderly were significantly more often diagnosed with mood disorders, especially depressive disorders. Interventions/recommendations made for Caucasian and African-American elderly did not differ for the most part. Recommendations for legal measures were suggested for African-American elderly more often than for Caucasians. Differences between Caucasian and African-American elderly were observed in consultation referral rates, reasons for referral, and psychiatric diagnoses made. The potential impact of cultural variables and the racial and age differences between hospital staff and patients may account for some of these findings. Further awareness of the needs of African-American elderly is required.

Effects of hypothalamic knife cuts and experience on maternal behavior in the rat

Recent investigations suggest that the disruption of placentophagia, pup-directed maternal behavior, and nestbuilding seen after lesions of the medial preoptic area (MPO) or the lateral hypothalamus may be due to the interruption at different points of a single longitudinal neural system mediating these behaviors. To test this, we compared the effects of knife cuts on the lateral border of the MPO, and of the posterior medial forebrain bundle (MFB), with asymmetrical cuts combining a unilateral MPO cut with a contralateral MFB cut. We observed placentophagia, nestbuilding, and pup-directed maternal behaviors at, and after, parturition in both primiparous and biparous rats. In primiparae, MPO cuts (a) disrupted placentophagia, (b) delayed the onset of crouching and pup-licking, and (c) eliminated retrieval and nestbuilding. MFB cuts (a) disrupted placentophagia, (b) delayed the onset of maternal behavior, and (c) eliminated nestbuilding. Asymmetrical cuts (a) disrupted placentophagia, and (b) delayed the onset of maternal behavior. In biparous rats, MPO cuts eliminated nestbuilding and retrieval. MFB cuts (a) disrupted placentophagia, and (b) eliminated nestbuilding. Asymmetrical cuts (a) delayed nestbuilding. These results suggest the involvement of a longitudinal neural system in the production of immediate pup-directed maternal behavior, placentophagia, and nestbuilding in parturient primiparae, but which is not critical for the eventual display of maternal behavior and nestbuilding in maternally naive rats, nor for the immediate onset of placentophagia and maternal behavior in maternally experienced rats.

Lifetime exposure to adversity predicts functional impairment and healthcare utilization among individuals with chronic back pain

&NA; Previous research has demonstrated an association between lifetime exposure to adverse events and chronic back pain (CBP), but the nature of this relationship has not been fully specified. Adversity exposure typically predicts undesirable outcomes, suggesting that lack of all adversity is optimal. However, we hypothesized that among individuals faced with CBP, a history of a low level of lifetime adversity would yield protective effects, manifested as lower impairment and healthcare utilization. Adult members of a national panel (N = 396) endorsed a history of CBP when reporting their physical health status in an online survey; they further reported their functional impairment and healthcare utilization. Respondents had previously completed a survey of lifetime exposure to adverse events. Significant U‐shaped quadratic relationships emerged between adversity and self‐rated functional impairment (p < 0.001), disabled employment status (p < 0.001), frequency of physician/clinic visits for CBP (p < 0.01), prescription (but not over‐the‐counter) analgesic use (p < 0.01), and comorbid depression treatment seeking (p < 0.01). Specifically, people with some lifetime adversity reported less impairment and healthcare utilization than people who had experienced either no adversity or a high level of adversity. Additional analyses failed to support alternative explanations of the findings. Implications for understanding and promoting resilience in the context of CBP are discussed.

Psychiatric consultation in the nursing home: Referral patterns and recognition of depression

OBJECTIVE To assess the accuracy of referrals to psychiatric consultants for depression (or depression-related disorders) among nursing home residents. METHODS Retrospective review of psychiatric consultations for nursing home residents in six facilities for a 3-year period. Reasons for referral, assigned diagnoses, rates of accuracy, sensitivity and specificity were examined to assess patterns of referral and recognition of clinical variants of depressive disorders. RESULTS Referrals for depression comprised 19.7% of all requested consultations. Of patients referred for depression, 74.2% were diagnosed with a depressive disorder. Of all residents diagnosed with depressive disorders, 53.5% were referred for other reasons. Men were referred for evaluation of depression significantly more often than women. However, rates of diagnosis of depression did not appear to differ significantly between men and women. CONCLUSIONS Nursing home staff often failed to recognize depression. Depressed residents are primarily referred for disruptive behaviors. Referrals for depression may be a secondary concern.