Research Roundup 1997

Intellectual Decline and Schizophrenia IV Clomipramine

PBI Chronic Fatigue Lithium Prophylaxis

Neuroleptic Resistance Treatments for PTSD Debriefing for PTSD

Schizophrenia and the myth of intellectual decline

Ailsa Russell and colleagues from the Institute of Psychiatry and Nottingham University published results of a study looking at the childhood IQs of 34 people who later developed schizophrenia (Am J Psych, 1997, 154). The mean child and adult IQs were greater than one standard deviation lower than the general population. There were no significant differences between the child and adult IQs, however, suggesting that the impairment in intelligence during childhood was stable over the follow-up period. Thus it would appear that the deficit in IQ in these patients is lifelong and predates the clinical onset of schizophrenia.

Intravenous clomipramine is a therapy that is rarely used nowadays. Sallee et al (Am J Psych 1997 154:668-673) published a fascinating study of its use in depressed adolescents. This double - blind controlled trial indicated that iv clomipramine infusions (25mg in 500 ml of saline given over three hours daily) improved mood significantly (compared to placebo) and rapidly (within 6 days).

Murphy, Brewin & Silka (Psychological Medicine, 1997, 27 333-342) looked at the Parental Bonding Instrument, which is a widely used measure of remembered parenting. The PBI is usually used to measure two dimensions: care and over-protection.

This study factor analysed the PBI results of 583 US and 236 UK students to see whether a two-factor solution or a three factor solution was most appropriate. They found that the latter was the best fit and suggest that care, denial of psychological autonomy, and encouragement of behavioural freedom should be used in a modified PBI.

Lawrie et al (Psychological Medicine 1997, 27, 343-353) performed a population based incidence study for chronic fatigue. They sent questionnaires assessing fatigue and emotional morbidity to 695 adult men and women who had replied to a postal survey the previous year. Possible CFS cases, possible psychiatric cases and normal controls were interviewed. Premorbid fatigue score was the only significant predictor. Possible CFS cases reported similar levels of current and past psychiatric disorder to psychiatric controls. There were four new chronic fatigue cases.

Studies of the prophylactic effects of lithium in bipolar affective disorder have confirmed its short-term efficacy, but its long-term efficacy is less clearly established. Coryell et al (1997 Psychological Medicine, 27, 281-289) studied 181 patients, 139 of whom were taking lithium. Lithium prophylaxis reduced the likelihood of recurrence in the first 32 weeks of recovery, but this effect did not appear to persist in the remaining five years of the study. The authors suggest a controlled lithium discontinuation study with gradual taper of patients who have had at least 8 months of sustained euthymia. Mean lithium levels for the lithium group generally exceeded 0.8 meq/l.

Meltzer et al (Am J Psych, 1997; 154:475 482) looked at neuroleptic resistance in 322 patients with schizophrenia. Analysis of variance showed significant relationships between age at onset and gender. Early onset of schizophrenia may foreshadow neuroleptic resistance. Difference in age of onset between males and females was less for treatment resistant patients than neuroleptic responsive patients. Their suggestion is that neuroleptic resistant patients differ premorbidly as well as after the onset of the illness.

Which treatments for post-traumatic stress disorder are effective? Data about the efficacy of psychotherapy and counselling is scarce. A study by Goenjian etal (1997; 154:536-542) is teherfore welcome. This study looked at brief trauma/grief focused psychotherapy among young adolescents exposed to the 1988 earthquake in Armenia. This school-based intervention appeared to protect against worsening of depressive symptoms in the treatment group compared to the control group. The treatment group had a significant reduction in post-traumatic symptoms. Subjects were evaluated at intervals over a three year period.

Who is likely to get PTSD? Shalev et al (BJPsych, 1997, 170, 558-564) looked at a range of questionnaires and structured clinical interviews and their ability to predict PTSD in recent trauma survivors from and Emergency Department in Istrael. They looked at:

  • Horowitz's Impact of Event Scale (IES)
  • Spielberger's State Anxiety (SANX)
  • Peritraumatic Dissociation Questionnaire (PDEQ)
  • Mississippi Scale for Combat-Related PTSD (MISS) and the
  • Clinician Administered PTSD Scale (CAPS)

All questionnaires appeared to be better than chance at predicting PTSD, but the specific PTSD questionnaires (IES and MISS) appeared to be no better than the general ones.The CAPS appeared to be superior at predicting PTSD, but as a screening instrument it would be very expensive in terms of people and time. No particular questionnaire seems to have the required specificity.

Citalopram appears to be a safe, highly selective and relatively under-used antidepressant. 475 patients with panic disorder were randomised to treatment with placebo, clomipramine or citalopram (Wade et al, 1997, BJPsych, 170, 549-553). Treatment with citalopram at 20, 30, 40 and 60 mg and clomipramine were both superior to placebo. The most advantageous doses of citalopram were 20 and 30 mg per day.

Debriefing for PTSD

Bisson et al (Br J Psychiatry, 171, 78-91) studied 133 adult burn trauma victims. They were randomised into two groups - one with psychological debriefing and one control group with no intervention. At follow up 13 months later 26% of the debriefed pateints had PTSD compared to only 9% of the control group. The authors conclude: 'This study seriously questions the wisdom of advocating one-off interventions post-trauma, and should stimulate research into more effective initiatives'


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