Depression Brain Imaging in OCD Development of Personality Disorders
Cerebral Blood Flow in OCD Humoral Phototransduction Poor Statistics
13 Year Outcome in Schizophrenia

Depression

Most trials of treatments for depression focus on the hospital or the outpatient department. A recent randomized controlled trial looked at standardized treatments in primary care. Patients received nortriptyline (91) or interpersonal psychotherapy (93) or a physician's normal care (92). 70% of patients in the pharmacotherapy or psychotherapy groups were judged recovered at 8 months compared to only 20% of 'usual care' patients. Twelve to sixteen sessions of IPT are advocated.(Treating Major Depression in Primary Care Practice - 8 month clinical outcomes by Schulberg H C et al, 1996 - Arch Gen Psychiatry 53, 913-919).

Of interest to liaison psychiatrists is a study in the Archives of General Psychiatry (Henk, H J et al 1996, 53, 899-904) entitled Medical Costs attributed to Depression among patients with a history of high medical expenses in a health maintenance organization. This looked at the medical utilization costs of 50 000 patients enrolled in the DeanCare (a health maintenance organization) for two years. A depression screen was mailed to 786 high utilizers. Depressed patients costs were significantly higher (p<.001) The additional cost per patient was $1498 per annum adjusted for age, sex, benefits package and medical co-morbidity. Treatment costs accounted for only a small percentage of total medical costs for depressed high utilizers in the third year - suggesting a direct cost-benefit to depression treatment. 

Brain Imaging in Obsessive Compulsive Disorder

Three research papers in a recent edition of Archives of Psychiatry focus on brain imaging in obsessive compulsive disorder(OCD). The first (Aylward et al, 1996; 53: 577-584) examined the brains of 24 patients with adult-onset OCD and 21 controls. Measurements of the basal ganglia did not demonstrate any differences. Theories of OCD have included dysfunction of the basal ganglia. This theoretical framework of caudate dysfunction is not underpinned by consistent structural or functional neuroimaging.

The second paper concerned functional MRI scanning during periods of controlled symptoms and provoked symptoms in each of ten patients (Breiter et al, 1996;53:595-606) and simulation in five normal subjects .

Symptom provocation involved imaginary scenarios and in vivo flooding. Excess brain activity was mapped in the medial orbitofrontal, lateral frontal, anterior temporal, anterior cingulate, and insular cortex together with basal ganglia. Limbic activations were particularly prominent.

The third paper (Jenike et al, 1996;53:625-632) quantified MRI scans of 10 female OCD patients and 10 controls. Patients with OCD had significantly less total white matter, but significantly greater total cortex and opercular volumes. Severity of OCD (measured by the Yale-Brown Obsessive Compulsive Scale) correlated with opercular volume.

The Development of Personality Disorders

An important longitudinal study of 641 youths who were assessed in childhood and then 10 years later was published in the American Journal of Psychiatry (Bernstein et al, 1996; 153: 907-913). Childhood conduct problems were an independent predictor of all three clusters of personality disorders (A, B and C) in DSM-III-R. Depressive symptoms in boys were a predictor of Cluster A personality disorders and immaturity was a predictor of Cluster B personality disorders in girls. Measures of childhood problems were derived by higher order principal component analysis of childhood behavioural ratings. Four measures of problems were used: conduct problems, depressive symptoms, anxiety/fear and immaturity. Personality disorders do therefore reflect longstanding personality dysfunction.

Humoral phototransduction?

An interesting hypothesis has been put forward by Oren in The Neuroscientist (2, 4, 207-211, 1996). Oren puts forward the hypothesis that haem moieties and bile pigments in animals may mediate some light influences upon neuroactive gases and biological rhythms ie the concept of humoral phototransduction. Oren states that like chlorophylls the haem tetrapyrrole structure has a similar capacity to transduce photic energy. He says that the biconcave erythrocyte has an ideal gas exchange & light absorption area/volume ratio. Blood flow through the retina and humoral phototransduction may offer a model for the known effects of light upon non-enucleated blind animals and people.

The model has interesting possibilities for the direction of research into psychiatric disorders like seasonal affective disorder.

Poor Statistics in the British Journal of Psychiatry

BJPsych, 167, 683-688.

In a brave model of openness, the BJPsych published a paper by McGuigan stating that at least 40% of papers in the BJPsych have statistical errors; errors serious enough in some cases to throw doubt on the conclusions of researchers. The paper in the BJPsych calls this error rate is 'unacceptably high'.

Cerebral Blood Flow in Obsessive-Compulsive Disorder

BJPsych, 167, 629-634.

Lucey et al report the results of a study looking at 30 outpatients from the Maudsley Hospital with DSM-III-R criteria primary OCD. On SPET scanning, compared to 30 healthy controls, regional cerebral blood flow was significantly reduced in OCD patients (and not related to overall reduced perfusion). Reduced flow in the right inferior frontal cortex appeared to correlate with illness severity. The authors state that this reduced perfusion was not associated with age, age of onset, sex, handedness, depression or medication, (which is as well since nearly a third of the patients' group were taking either fluoxetine or clomipramine).

13-year outcome in schizophrenia

BJPsych, 167, 596-603.

Mason et al report a study of the outcome of 67 patients with ICD-9 schizophrenia 13 years later. 83% of the sample were 'either (sic) dead, showed some degrees of symptomatic or social disability, or continued in some form of continued treatment'. 44% had a mild/recovered treated outcome. The authors cite others' gloomy interpretions of Kraepelin's 1919 prognosis and conclude that Kraepelin's outcome is 'far too pessimistic'. However the authors singularly fail to consider that this comparison is spurious, since Kraepelin was documenting a group of ill people (with dementia praecox) with no effective treatments at all.

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