William Sack

Efficacy of Paroxetine in the Treatment of Adolescent Major Depression: A Randomized, Controlled Trial

OBJECTIVE To compare paroxetine with placebo and imipramine with placebo for the treatment of adolescent depression. METHOD After a 7- to 14-day screening period, 275 adolescents with major depression began 8 weeks of double-blind paroxetine (20-40 mg), imipramine (gradual upward titration to 200-300 mg), or placebo. The two primary outcome measures were endpoint response (Hamilton Rating Scale for Depression [HAM-D] score < or = 8 or > or = 50% reduction in baseline HAM-D) and change from baseline HAM-D score. Other depression-related variables were (1) HAM-D depressed mood item; (2) depression item of the Schedule for Affective Disorders and Schizophrenia for Adolescents-Lifetime version (K-SADS-L); (3) Clinical Global Impression (CGI) improvement scores of 1 or 2; (4) nine-item depression subscale of K-SADS-L; and (5) mean CGI improvement scores. RESULTS Paroxetine demonstrated significantly greater improvement compared with placebo in HAM-D total score < or = 8, HAM-D depressed mood item, K-SADS-L depressed mood item, and CGI score of 1 or 2. The response to imipramine was not significantly different from placebo for any measure. Neither paroxetine nor imipramine differed significantly from placebo on parent- or self-rating measures. Withdrawal rates for adverse effects were 9.7% and 6.9% for paroxetine and placebo, respectively. Of 31.5% of subjects stopping imipramine therapy because of adverse effects, nearly one third did so because of adverse cardiovascular effects. CONCLUSIONS Paroxetine is generally well tolerated and effective for major depression in adolescents.

Lifetime comorbidity among anxiety disorders and between anxiety disorders and other mental disorders in adolescents

We examine the lifetime comorbidity among anxiety disorders, and between anxiety disorders and other mental disorders, in a large (n = 1,507) community sample of high school students on whom extensive diagnostic data were available. Three diagnostic groups were formed: those with a lifetime anxiety disorder (n = 134); those with a nonanxiety disorder (n = 510); and those who had never met criteria for a mental disorder (n = 863). The intra-anxiety comorbidity rate was relatively low (18.7%), and was strongly associated with being female (92%). The lifetime comorbidity between anxiety and other mental disorders (primarily MDD) was substantial (73.1%) and was not associated with being female.

A three-year follow-up of Cambodian young people traumatized as children.

Twenty-seven Cambodian young people, who were severely traumatized at ages 8 to 12, were followed up 3 years after an original study. A structured interview and self-rating scales showed that post-traumatic stress disorders (PTSD) were still highly prevalent (48%). Depression existed in 41%. Those with PTSD differed significantly from those without PTSD on the Global Adjustment Scale, the Social Adjustment Scale, the Beck Depression Inventory, and the Impact of Event Scale. Eight subjects had PTSD at both interviews, while 11 had none at either time. Eight showed a variable course. Avoidance behavior was highly prevalent, even among those without PTSD diagnosis. Although functioning relatively well, these youths continued to show symptoms related to their trauma of 8 to 12 years before.

Posttraumatic stress disorder across two generations of Cambodian refugees.

OBJECTIVE To examine the expression of war-related trauma as manifested by DSM-III-R rates of posttraumatic stress disorder (PTSD) and major depressive disorder in two generations of Cambodian refugees living in the western United States. METHOD A probability sample of 209 Khmer adolescents and one of their parents were interviewed using portions of the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Epidemiologic Version and the PTSD section of the Diagnostic Interview for Children and Adolescents. Interviews were conducted in English by a masters-level clinician with a Khmer interpreter. RESULTS PTSD was found to be significantly related across parent-child generations. A nonsignificant generational trend was also found for depressive disorders. A number of environmental variables measured in the study (amount of reported war trauma, loss, living arrangements, treatment received, socioeconomic status) were not related to these findings. Parents were more likely to report an earlier onset of PTSD symptoms. CONCLUSIONS This study suggests that PTSD in refugees may cluster in families. Whether this phenomenon is caused by a genetic susceptibility to trauma awaits further research. PTSD and depressive disorders in refugee populations, while often comorbid, appear to follow different courses over time.

Twelve-year follow-up study of Khmer youths who suffered massive war trauma as children.

OBJECTIVE Twenty-seven of 40 Khmer adolescent youths who had survived the horrors of the Pol Pot regime (1975-1979) as children and 4 of 6 who had escaped this war were reinterviewed for the fourth time, during the summer of 1996, to determine their diagnostic status for posttraumatic stress disorder (PTSD) and/or depression and their functional status with regard to occupational and/or educational pursuits. They had been interviewed initially in 1983-1984 and again 3 (1987) and 6 (1990-1991) years later. METHOD PTSD was determined using the Diagnostic Interview for Children and Adolescents, and depression was assessed using the Schedule for Affective Disorders and Schizophrenia for School-Age Children. RESULTS The point prevalence rates of PTSD were comparable with those found 6 years earlier, and rates of depression were much lower but had increased somewhat over the ensuing 6 years. The onset of PTSD was quite variable, with 18% of subjects (7/40) developing PTSD at least 5 years after cessation of the Pol Pot hostilities. Subjects with PTSD were more likely to recall specifically traumatic war memories, whereas those without PTSD were more likely to recall memories of loss and/or displacement. Most subjects were functioning well, regardless of diagnostic status. CONCLUSIONS Although its onset is quite variable, PTSD persists in war-traumatized Cambodian refugee youths. PTSD and depression appear to follow different pathways over time. PTSD need not be associated with major functional impairment.

A 6-Year Follow-up Study of Cambodian Refugee Adolescents Traumatized as Children

Seventy-three percent of a sample of 46 Cambodian youth interviewed in 1984 and 1987 were reinterviewed in 1990 as part of a pretest for a multisite study of Cambodian refugee trauma now under way. An additional sample of convenience of 38 youth were also interviewed to determine reliability and validity of the diagnostic instruments chosen for the larger study. The DSM-III-R diagnosis of post-traumatic stress disorder (PTSD) was found to persist, but the symptoms appeared less intense over time. In contrast, the prevalence of depression dropped markedly since 1987. Subjects remained largely free of comorbid conditions. Diagnostic reliability and validity were satisfactory. The follow-up sample appeared to be functioning well despite their PTSD profiles. The findings are discussed in light of several current controversies surrounding the concept and measurement of PTSD.

The Khmer Adolescent Project. I. Epidemiologic findings in two generations of Cambodian refugees.

A nonstratified random sample of 209 Khmer adolescents, ages 13 to 25, and a parent or guardian from two Western communities were interviewed to determine their diagnostic status following their survival of the Pol Pot War in Cambodia, from 1975 to 1979. Subjects were administered the posttraumatic stress disorder section of the Diagnostic Instrument for Children and Adolescents and selected sections of the Schedule of Affective Disorders and Schizophrenia for School-Age Children-Epidemiologic Version, with the assistance of a Cambodian translator. Roughly one fifth of the adolescents, over one half of the mothers, and about one third of the fathers qualified for a current diagnosis of posttraumatic stress disorder. There was high comorbidity with depression, but other forms of psychopathology were much less evident. The clinical importance of distinguishing prior trauma from other forms of cultural loss and resettlement stress is discussed.

Does PTSD transcend cultural barriers? A study from the Khmer Adolescent Refugee Project.

OBJECTIVE To determine whether the factor structure of the posttraumatic stress disorder (PTSD) syndrome in Cambodian refugee youth resembles earlier reported factor studies in Caucasian samples. METHOD 194 Khmer adolescent refugees who reported prior significant trauma (most of it massive war trauma as children) were administered the PTSD module of the Diagnostic interview for Children and Adolescents, as part of an epidemiological study on the effects of war on this group of refugees. RESULTS The following four factors were found: arousal, avoidance, intrusion, and numbing. A confirmatory factor analysis using data from the parents of this sample yielded a good fit for the four-factor solution based on the youth data. CONCLUSIONS The four-factor solution from this sample resembled earlier studies on traumatized Caucasian and African-American adults. These results lend further credibility to the veracity of this diagnosis with refugee samples. PTSD as a result of prior war trauma appears to surmount the barriers of culture and language in this sample.

The Psychiatric Effects of Massive Trauma on Cambodian Children: II. The Family, the Home, and the School

Forty Cambodian high school students who survived 4 years under the Pol Pot regime (1975–1979) and 6 Cambodian students who escaped their homeland prior to Pol Pot were studied by means of home interviews and school teacher ratings. In these findings, compared to psychiatric interview data on the same subjects, students reported more distress with school grades, peers and themselves than was observed by their caretakers. Many of their family members exhibited similar posttraumatic stress and depressive symptoms. In school, students receiving a psychiatric diagnosis were more likely to be rated by their classroom teachers as withdrawn or daydreaming than as disruptive. The crucial role of the school as a cultural agent of change became strongly evident.

Psychiatric Disorder Among American Indian Adolescents: Prevalence in Northern Plains Youth

UNLABELLED This article presents data on the prevalence of psychiatric disorders among American Indian adolescents, using DSM-III-R criteria. OBJECTIVE To generate current prevalence data using a structured diagnostic instrument, the Diagnostic Interview Schedule for Children, Version 2.1C (DISC-2.1C). METHODS Youths from a Northern Plains tribe who had participated in an earlier study comprised the sample. At reinterview, respondents were between 14 and 16 years of age, when Indian adolescents are thought to be at particularly high risk for manifesting emotional disorders. One hundred nine of the original sample of 251 were still in schools on the reservation. Trained indigenous lay interviewers administered the DISC-2.1C to respondents in a private setting within the school. RESULTS The findings indicate that rates of some psychiatric problems (e.g., disruptive behavior disorders, substance-related disorders, and their comorbidity) are high among these high school students. CONCLUSIONS These data, as well as national statistics, suggest that, compared with non-Indian populations, a greater percentage of Northern Plains adolescents manifest significant psychiatric symptoms which warrant treatment.