Several psychiatric disorders, including borderline personality disorder (BPD), are characterized by emotional dysregulation and impulse dyscontrol. More specifically, symptoms in patients with BPD often occur within the context of disruptions in attachment and related distortions in cognitive-affective processing of the self and others. From a neurocircuitry perspective, findings include prefrontal hypoactivity, amygdala hyperreactivity, and alterations in prefrontal-limbic interaction. Molecular pathways relevant to these circuits include the serotonergic, noradrenergic, and dopaminergic systems, and there is some evidence that pharmacotherapy with agents that act on these systems may be useful. Given the disruptions in attachment and schemas of the self and others in BPD, establishing a therapeutic alliance is crucial while psychotherapy remains the cornerstone of an integrated approach to management.

Introduction: The co-occurrence of obsessive-compulsive disorder (OCD) in patients with schizophrenia and related disorders has been increasingly recognized. However, the rate of psychosis comorbidity in OCD patients has yet to be systematically evaluated.

Methods: The prevalence of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition psychotic disorders was evaluated in 757 subjects consecutively referred to a specialised diagnostic and treatment facility for OCD. Demographic and clinical characteristics were assessed.

Results: Thirteen OCD patients (1.7%) also met the DSM-IV criteria for a psychotic disorder. We found no significant differences in clinical characteristic between OCD patients with and without a psychotic disorder, although patients with OCD and a psychotic disorder more likely used illicit substances and more likely were male.

Conclusion: Relatively few patients referred to a specialized treatment OCD center suffer from a psychotic disorder.

Objective: To determine the adequacy of pharmacotherapy received by patients with newly-diagnosed obsessive-compulsive disorder (OCD), based on current practice guidelines.

Methods: A 9 year (1997–2006) retrospective claims analysis of adults enrolled in Florida Medicaid for at least 3 continuous years was conducted to determine the percentage who received both a minimally effective duration (≥ 8 continuous weeks) and dose of first-line OCD pharmacotherapy during the year following their first (“index”) OCD diagnosis.

Results: Among 2,960,421 adult (≥ 18 years of age) enrollees, 2,921 (0.1%) were diagnosed with OCD. Among the 2,825 OCD patients without comorbid Asperger syndrome or autism, 843 had newly-diagnosed OCD and at least 12 months of follow-up data after their index diagnosis. Among these 843 patients, 588 (69.7%) received first-line OCD pharmacotherapy but only 323 (38.3%) received a minimally effective pharmacotherapy trial in the year following their index diagnosis.

Conclusions: Among clinically-diagnosed persons with OCD (<10% of those with the disorder), a minority of newly-diagnosed patients receive a minimally effective pharmacotherapy trial consistent with current standards of care. Reasons such as limited patient adherence and/or physician awareness of guidelines must be identified and redressed to ameliorate the patient, healthcare system, and economic burdens associated with OCD.

Introduction: Prior research suggests that racial minority groups in the United States are more vulnerable to develop a gambling disorder than whites. However, no national survey on gambling disorders exists that has focused on ethnic differences.

Methods: Analyses of this study were based on the National Epidemiologic Survey on Alcohol and Related Conditions, a large (N=43,093) nationally representative survey of the adult (≥18 years of age) population residing in house-holds during 2001–2002 period. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision diagnoses of pathological gambling, mood, anxiety, drug use, and personality disorders were based on the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IVVersion.

Results: Prevalence rates of disordered gambling among blacks (2.2%) and Native/Asian Americans (2.3%) were higher than that of whites (1.2%). Demographic characteristics and psychiatric comorbidity differed among Hispanic, black, and white disordered gamblers. However, all racial and ethnic groups evidenced similarities with respect to symptom patterns, time course, and treatment seeking for pathological gambling.

Conclusion: The prevalence of disordered gambling, but not its onset or course of symptoms, varies by racial and ethnic group. These varying prevalence rates may reflect, at least in part, cultural differences in gambling and its acceptability and accessibility. These data may inform the need for targeted prevention strategies for high-risk racial and ethnic groups.

Introduction: To assess the efficacy of desvenlafaxine (administered as desvenlafaxine succinate) in outpatients with major depressive disorder.

Methods: A meta-analysis of individual patient data was performed on the complete set of registration trials (nine randomized, double-blind, placebo-controlled 8-week studies) of desvenlafaxine. Patients received fixed (50, 100, 200, or 400 mg/day; n = 1,342) or flexible doses (100–400 mg/day; n = 463) of desvenlafaxine or placebo (n = 1,108). The primary efficacy variable was the 17-item Hamilton Rating Scale for Depression (HAM-D17); the primary intent to treat analyses used the last-observation-carried-forward method.

Results: Significantly greater improvement with desvenlafaxine versus placebo on the HAM-D17 total score was observed for the full data set (difference in adjusted means: −1.9; P<.001), each fixed-dose group (all P<.001), and the flexible-dose group (P=.024). Overall rates of HAM-D17 response (≥50% decrease from baseline score: 53% vs 41%) and remission (HAM-D17 ≤7: 32% vs 23%) were significantly greater for desvenlafaxine versus placebo (all P<.001). Discontinuation rates due to adverse events increased with dose (4% to 18%; placebo: 3%).

Conclusion: Desvenlafaxine demonstrated short-term efficacy for treating major depressive disorder across the range of doses studied. No evidence of greater efficacy was observed with doses >50 mg/day; a strong dose-response effect on tolerability was observed.

Introduction: Although obsessions and compulsions comprise the main features of obsessive-compulsive disorder (OCD), many patients report that their compulsions are preceded by a sense of “incompleteness” or other unpleasant feelings such as premonitory urges or a need perform actions until feeling “just right.” These manifestations have been characterized as Sensory Phenomena (SP). The current study presents initial psychometric data for a new scale designed to measure SP.

Methods: Seventy-six adult OCD subjects were probed twice. Patients were assessed with an open clinical interview (considered as the “gold standard”) and with the following standardized instruments: Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis I Disorders, Yale-Brown Obsessive-Compulsive Scale, Dimensional Yale-Brown Obsessive-Compulsive Scale, Yale Global Tic Severity Scale, Beck Anxiety Inventory, and Beck Depression Inventory.

Results: SP were present in 51 OCD patients (67.1%). Tics were present in 16 (21.1%) of the overall sample. The presence of SP was significantly higher in early-onset OCD patients. There were no significant differences in the presence of SP according to comorbidity with tics or gender. The comparison between the results from the open clinical interviews and the University of São Paulo Sensory Phenomena Scale (USP-SPS) showed an excellent concordance between them, with no significant differences between interviewers. The inter-rater reliability between the expert raters for the USP-SPS was high, with K=.92. The Pearson correlation coefficient between the SP severity scores given by the two raters was .89.

Conclusion: Preliminary results suggest that the USP-SPS is a valid and reliable instrument for assessing the presence and severity of SP in OCD subjects.

Introduction: Complementary and alternative medicine (CAM) modalities are gaining popularity among patients in Western countries. They are especially popular among patients seeking treatment for mental and mood symptoms. Some CAMs are according to current Western approaches but have not achieved approval by regulatory agencies. Some other modalities are acording to non-Western concepts of mental order and disorder. This installment of “The Well-Rounded Brain” will illuminate some non-Western concepts with an example of treatment modality for affective disorders, and compare them to conventional Western approach.

Methods: Principles of the Chinese concept of affective disorders and acupuncture modalities for their treatments are briefly described from a culturally sensitive perspective.

Results: Traditional Chinese medicine and current conventional Western medicine substantially differ in underlying concepts, development of treatment modalities, as well as their goals and implementation.

Conclusion: Some non-Western concepts and treatment modalities have been meticulously and rigorously developed through trial and error, though the evidence for their efficacy and efficiency is not necessarily according to current Western standards. The consistent epidemiological demonstrations of the demand for CAM among patients suffering from mental disorders call for an open-minded, unbiased assessment of efficacy of non-Western treatment modalities for specific clusters of affective symptoms.

N-acetyl cysteine (NAC) is a widely available nutraceutical with a variety of actions. As a precursor of cysteine and glutathione, it has antioxidant properties that may impact on mood and contribute to an effect on impulsivity and obsessive behaviour. Via its additional effect on glutamate via the cystine-glutamate exchange system, NAC has been shown to mediate impulsivity in preclinical models of addiction, reduce craving, and cue extinction. Further, by boosting glutathione, NAC acts as a potent antioxidant and has been shown in two positive, large-scale randomized placebo-controlled trials to affect negative symptoms in schizophrenia and depression in bipolar disorder. We describe three cases in which its actions specifically on nail-biting and associated anxiety may offer a potential treatment. The spontaneous findings are reported as part of an ongoing treatment trial examining the utility of NAC in bipolar disorder. Its actions, if robustly replicated, also point to potential treatment targets in glutathione or glutamate pathways in the brain.

It is estimated that 15 million Americans have a depressive disorder, including major depressive disorder, and many of those afflicted do not receive recommended guideline levels of care. Of patients who are correctly diagnosed with depression, a majority of patients do not recover by 4-6 months, often due to discontinuing treatment prior to the initiation of therapeutic effect. It is important for clinicians to understand the factors involved in nonadherence to treatment for the depressive disorders, including presence of residual symptoms, younger age, and less educational attainment. Once clinicians believe a patient is at risk for nonadherence—which is the rule rather than the exception—health care professionals have various techniques available to increase treatment adherence, including communication techniques and other health care interventions.

In this Expert Panel Supplement, Richard C. Shelton, MD, reviews data from the Sequenced Treatment Alternatives to Relieve Depression study to determine the role residual depressive symptoms have in causing patients to become nonadherent to treatment as well as defines characteristics common to patients who discontinue their medications. Steven R. Hahn, MD, outlines several strategies for improving adherence among patients, including a four-step process to bolster patient comfort with treatment guidelines and “Ask-Tell-Ask,” a communication technique aimed to provide clinicians additional understanding as to patient attitudes and beliefs. Finally, Wayne J. Katon, MD, describes how collaborative care—a health care model that involves not only primary care but also additional health care providers in patient treatment—can be beneficial in improving adherence by providing further patient education and additional screening to ensure that patients remain adherent to antidepressants.