Current Psychiatry Reviews - Volume 4, Issue 1, 2008

This issue of Current Psychiatry Reviews, the first of volume 4, marks our transition from a more conventional “hard copy” format to that of electronic publication. Some of us who came of age in the era prior to the internet have embraced this 21st Century way of doing things with enthusiasm; for others, the prospects of a journal that only exists in the ether so to speak is an unsettling endeavor. There is no doubt, however, that we are ahead of the curve in this regard: electronic publication is more efficient and that it will permit our journal to accomplish our aims of rapid publication of state-of-the-science reviews across a broad range of topics that are of interest to psychiatrists and other mental health professionals. This particular issue of Current Psychiatry Reviews, for example, includes an article examining the elevated risk of Alzheimer's disease among African- Americans by Stephanie Kirbach, two articles on Schizophrenia (Glenn Shean's “Evidence Based Psychosocial Practices and Recovery from Schizophrenia” and “Measures of Functional Status and Quality-of-Life in Schizophrenia” by Mark Price), and articles by Andrew Chanen, Joel Paris, and Mark Zeigenbein reviewing various aspects of Axis II disorders. In addition, Ihsan Salloum - my longtime and excellent collaborator from our days at the University of Pittsburgh Medical Center - has prepared a systematic review on the data on antidepressant treatment of depression in people with substance abuse disorders. I hope that you will enjoy this selection of reviews and that you continue to think of Current Psychiatry Reviews as a potential home for your scholarly reviews.

Pessimistic views about the course and outcome of schizophrenia have been replaced by a more optimistic approach that places emphasis on providing services in the community that foster functional recovery. The concept of recovery implies emphasis on the importance of providing access to treatments and community services that assist individuals to lead maximally productive and personally meaningful lives. Research conducted by the World Health Organization on the course and outcome of schizophrenia contributed to growing recognition of the importance of community based psychosocial therapy and rehabilitation programs in improving prospects for recovery. The Schizophrenia Patient Outcomes Research Team (PORT) recently published an updated consensus list of twenty evidence-based practices (EBPs) that includes six psychosocial treatments. The PORT psychosocial EBPs are summarized in this paper, and factors that impact program effectiveness are discussed. These factors include stigma, and variations in the quality and integrity of implementation of programs. The PORT recommendations are an excellent foundation on which to build future innovation and research on psychosocial approaches to improve opportunities for recovery of individuals diagnosed with schizophrenia.

Research on personality disorders (PD) has made progress in several areas. 1) Classification: Most PDs are exaggerations of normal traits and can be described dimensionally, but highly symptomatic PDs may not be well described in this way. Attempts to redefine PDs as variants of Axis I categories, such as depression and bipolar disorder, have been unconvincing. 2) Epidemiology: Recent community surveys suggest that PDs as currently defined have an overall prevalence of around 10%. 3) Etiology: Studies of relationships between PDs and neuroimaging, neuropsychological testing, neurotransmitters, and candidate genes are not related specifically to disorders, although certain markers are linked to traits. The complex pathways to PDs depend on gene-environment interactions. 4) Outcome: PD categories tend to be unstable over time, largely because of symptom reduction. However the traits underlying disorders do not change, and many continue to have poor psychosocial functioning. 5) Treatment: Clinical trials show that a number of psychotherapeutic methods are effective, with improvement often occurring within a few months. In contrast, the results of pharmacological trials have been unimpressive and inconclusive.

Objective: There is little guidance for optimal pharmacotherapy for comorbid major depression and substance use disorder, the most frequently encountered comorbidity in clinical settings. We reviewed current evidence for effective treatments as reported by pharmacological trials specifically conducted to address this comorbidity. Data Sources: Studies were identified through computerized literature searches and from refereed articles from January 1966 through January of 2007. Randomized, placebo-controlled trials and open-label studies with large samples or those reporting novel approaches were selected for this review. Data Synthesis: The search identified twenty-seven studies, 23 of which were randomized, double-blind, placebocontrolled trials. Overall, treatment response was inconsistent among the different trials. More trials reported improvement for depression than improvement for substance use and rarely reported improvement in both outcomes. Trials with non-serotonergic reuptake inhibitor antidepressants reported more positive findings than those with SSRI's. Response varied by type of medication and study design. Conclusions: Antidepressants may provide improvement for depression when comorbid with substance use. There is less evidence of improvement for the substance use outcome, and there was rarely improvement on both outcomes. Addressing methodological challenges in future clinical trials is crucial for providing more consistent results that allow the construction of evidence-based algorithm for optimized interventions in this population.

Pharmacotherapy has been reasonably effective in treating positive symptoms associated with schizophrenia and less effective in treating negative symptoms. Humanistic outcomes - quality of life and functionality - are more difficult to assess than changes in symptom severity and are equally important in assessing the overall effectiveness of treatment. The correlation between negative symptoms and poorer outcomes in patients with schizophrenia underscores the need for more effective treatment, and a large number of instruments have been devised to provide quantitative assessment of the humanistic outcomes associated with the treatment of schizophrenia. Some were developed specifically for schizophrenia, and others were originally developed for other clinical conditions but later adapted for schizophrenia. The value of such instruments depends on their intrinsic validity, selection criteria, and how the selected instrument is used by physicians and other clinical professionals. This review is aimed at increasing clinicians’ awareness of these instruments and improving their ability to use them appropriately as an adjunct to sound clinical judgment. We provide an overview of the issues pertinent to the use of rating instruments for quality of life and functionality, and based on a literature search, we provide a brief description of the 20 instruments most commonly used to assess these humanistic outcomes in patients with schizophrenia. Each instrument is discussed in terms of content and organization, formal validation, and use in patients with schizophrenia. An accompanying table reveals the domains relating to quality of life and functionality addressed by each instrument.

The diagnosis of personality disorders is highly dependent on how a society views certain behavior. Self concept, adaptation and social context are important aspects of the cultural dimensions of personality disorders. However, the relevance and implications of the influence of sociocultural factors are seen differently. Accordingly, there are very distinct conceptional, nosological and diagnostic approaches for classifying personality dispositions and personality disorders in a cross-cultural perspective. The present paper describes the social and cultural context of migration from an European perspective. A review of the literature on mental health risk in immigrants is given, and special focus is placed on the impact of culture on the development of personality in general and on the emergence and manifestation versus prevention of personality disorders in specific. Due to globalization and migration processes clinicians and therapists are increasingly called upon to assess the level of personality functioning, not only in patients from different ethnic backgrounds, but also in traumatized refugees and migrants. Multiple social and cultural factors have an influence on each level of the diagnostic and therapeutic process. In addition to thorough background knowledge concerning trauma, migration and culture specific issues, cultural sensitivity and cultural competence are requisite for clinicians and therapists.

Borderline personality disorder (BPD) is associated with substantial psychosocial impairment, morbidity, mortality and high health resource utilization. These data make a compelling case for developing prevention and early intervention strategies for BPD. This review examines the BPD diagnosis in young people, along with prospective risk factors for and precursors to the development of BPD. It then considers the prospects for and potential risks and benefits associated with prevention and early intervention for BPD. It concludes that the BPD diagnosis in young people has similar reliability, validity and prevalence to BPD in adults and that BPD in young people almost certainly has serious and pervasive negative repercussions over subsequent decades. Current data are inadequate to inform specific universal or selective prevention programs for BPD. However, they do support including BPD prevention as an outcome when evaluating universal and/or selective interventions for a variety of mental health problems and adverse psychosocial outcomes. The data are stronger for developing indicated preventive interventions but the strongest data support early intervention for the emerging BPD phenotype. Early intervention programs will need to be realistic in their aims, require change in clinician attitudes and service systems and must be mindful of the risk of iatrogenic harm.

The number of individuals with Alzheimer's disease is expected to increase steadily over the next 50 years, and this is especially concerning to African-Americans as they currently carry a disproportionate burden of the disease as compared to Caucasians. In conjunction with the APOE allele, there exists a group of potentially treatable cardiovascular risk factors that appear to be implicated in this disparity. In this paper, we review the contribution of these risk factors to Alzheimer's disease as well as racial discrepancies in their prevalence. Along with diet, cholesterol, hypertension and type II diabetes mellitus, differences in APOE η4 burden and effect among African-Americans and Caucasians are also considered. We conclude that the topics under review warrant further investigation, especially given their modifiable nature and undeniable link to Alzheimer's disease.