Psychiatry RSS : Gourt

Stigma and exclusion [From the Trainee Editor]

Gender dysphoria: recognition and assessment [Articles]

The role of the mental health professional, and of the psychiatrist in particular, is evolving and changing. As the recognition of transsexualism and gender identity disorder expands across the transgender spectrum, it has been recommended that gender dysphoria should replace existing diagnostic terminology. Patient-focused care is evolving and this article considers the limitations of current healthcare settings and how the mental health professional can support patients undergoing the real-life experience. Differentiation from other mental health conditions that may present as gender dysphoria is outlined, as well as specific clinical situations.

Gender dysphoria: treatment and outcomes [Articles]

Once a formal diagnosis of gender dysphoria is established and comorbid disorders addressed, it is the role of the gender specialist to facilitate treatment according to agreed goals. This article reviews the treatment of gender dysphoria, including psychotherapy, and how eligibility and readiness for surgery are assessed. It considers issues facing transgender individuals detained in prison or psychiatric hospital, the factors that affect patients’ satisfaction with gender reassignment surgery and how the specialist can ensure a satisfactory outcome.

Psychotherapy for gender identity disorders [Articles]

This article describes a special adaptation of group psychotherapy as a psychological treatment for people with a variety of gender identity disorders. It can be used as an alternative to or concurrently with hormonal and/or surgical interventions for transgender people. It is also suitable for individuals whose gender identity disorder remains after physical interventions. The article draws from a UK specialist pilot for such a treatment service and describes the explicit aims of the psychotherapy, the specialist adaptation of therapeutic technique required and observed thematic features relevant to working in this specific field.

Fifty years after Frantz Fanon: beyond diversity [Articles]

Frantz Fanon (1925–1961), a West Indian of mixed race, was a French colonial psychiatrist trained in Lyon, France, who worked mainly in colonial North Africa between 1953 and 1957. He was one of the earliest psychiatrists to suggest that the lived experience of ethnic minorities within a discriminatory colonial environment could trigger mental illness. This article focuses on Fanon’s work and contributions to psychiatry, as well as his philosophy, advocacy for social inclusion and pioneering work in culturally relevant rehabilitation. It also examines what lessons could be learnt from his life’s work as a psychiatrist and traces his influence on a generation of psychiatric researchers, suggesting how his contribution may have influenced critical thought and current views.

Schizoaffective disorder [Refreshment]

The term ‘schizoaffective disorder’ has meant different things to different people over the 80 years since Kasanin described a series of cases with an admixture of schizophrenia-like and mood-like symptoms. This article provides a brief overview of the history of the concept, and suggests a parsimonious approach for clinicians.

Eating disorders: clinical features and the role of the general psychiatrist [Articles]

Although most patients with severe eating disorders are treated in specialist eating disorder services, general psychiatrists are often responsible for the care of many with mild to moderate disorder. Treating and supporting these patients in a non-specialist setting can sometimes be challenging but this need not be the case. Having a clear understanding of the clinical features of these conditions forms the foundation on which a comprehensive assessment and management plan can be made. We summarise the clinical features of eating disorders and explore the unique role of the general psychiatrist in identifying people with these conditions, supporting them and directing them into evidence-based treatments.

Personality disorder: its impact on staff and the role of supervision [Articles]

Over the past decade attention to the provision of healthcare for individuals with personality disorder, particularly those who pose a risk to others, has substantially increased. Keeping pace with such developments with a suitably trained, consistent and motivated workforce, interfacing health and criminal justice systems where necessary, presents an enormous challenge. Staff must be experts in managing conflict at every level, while sustaining an optimistic and therapeutic orientation. Boundaried relationships provide the context for recovery for patients. Key principles and practices likely to promote resilience in personality disorder services, with a focus on the role of supervision, are outlined in order to support staff in keeping themselves afloat, their patients safe, and their services on target.

Recollections of journey from Essex by John Clare [Mindreading]

This article examines John Clare’s prose account of his escape from High Beach Asylum in 1841. Clare has attracted attention for his nature poems as much as for his humble, peasant background and his well-described mental illness, including his asylum committals. Recollections of journey from Essex is unique as a piece of writing describing escape from an asylum and illustrating to some degree the mental state and experiences of a psychiatrically ill person in England in the mid-1800s.

Staging the HCR-20: towards successful implementation of team-based structured professional judgement schemes [Articles]

Structured professional judgement risk management schemes such as the Historical, Clinical, Risk Management – 20 (HCR-20) can be described as clinical guidelines produced by a collaborative process between mental health clinicians and researchers. The purpose is to provide clinicians with a framework to guide interventions designed to manage specific risks such as violence against others. The use of evidence-based clinical methods, especially in a multidisciplinary setting, is now commonly considered a best-practice approach when managing violence and related risks. This article describes some of the practical implementation challenges that may arise when using schemes such as the HCR-20 in multi-disciplinary team meetings.

Further rare and unusual dementias [Articles]

In the second of two articles on rare causes of dementia, the authors describe toxic, iatrogenic, nutritional, traumatic, metabolic, neoplastic and autoimmune causes of dementia. Disorders are graded according to their prevalence, to give an idea of the likelihood of their presentation. Guidance is given on the investigation of uncommon cognitive impairment and dementia, especially in early-onset illness.

Is evidence-based psychiatry a quagmire? [Correspondence]

Author's reply [Correspondence]

Physical health examination in Section 136 suites [Correspondence]

Author's reply [Correspondence]

Corrections [Corrections]

Psychiatry Adult jobs

All Psychiatry Adult jobs for Tue Feb 7 2012

Psychiatry Adult jobs in "Southeastern/South Shore of Boston" - MA

We have an outstanding on-going LOCUMS opportunity for an Adult Psychiatrist in the Southeastern/South Shore of Boston, MA. Board Certified is preferred but Board Eligible will

Psychiatry Adult jobs in "Greater Lehigh Valley" - PA

Our very prestigious client in the Greater Lehigh Valley area of PA is in need of a LOCUMS BC/BE Adult Psychiatrist. Board Certified is preferred but Board Eligible will

Psychiatry Adult jobs in "Greater Pittsburgh" - PA

Our client in the Greater Pittsburgh area of PA is in need of a BC/BE LOCUMS Psychiatrist to join their group. Board Certified is preferred but Board Eligible will be accepted.

Psychiatry Adult jobs in "Not Disclosed" - MO

A psychiatrist is needed on a locum tenens basis at the VA medical center in Mt. Vernon, Missouri. The assignment will begin as soon as credentialing can be completed and will continue for three months.

Psychiatry Adult jobs in "Not Disclosed" - PA

A psychiatrist is needed on a locum tenens basis at the VA medical center in Lebanon, Pennsylvania. The assignment will begin in February of 2012 and will continue until August 17, 2012. Currently, only

Psychiatry Adult jobs in "Not Disclosed" - CO

A facility in the Denver, CO area seeks ongoing locum tenens Psychiatry coverage. Coverage is requested to start as soon as your schedule allows and last through 2011 or until a permanent psychiatrist

Psychiatry Adult jobs in "North Western" - NJ

I am working with a client in North Western New Jersey that has a Psychiatry need starting ASAP. This need is for an Adult Psychiatrist working primarily outpatient but who would work 1 weekend day

Psychiatry Adult jobs in "Northeastern" - NY

We have an immediate need in upstate NY for a Psychatrist. Our client is recruiting on a full time basis but needs some locums help until the ideal perm candidate is identified and has started work. This

Psychiatry Adult jobs in "Southeastern" - MA

Enjoy coastal living and work in one of the Top 10 Health Systems in the country. Full-time, 32-hour-per-week position available immediately for Board Certified/Eligible Psychiatrist to share responsibilities

Psychiatry Adult jobs in "South Island" - NZ

Seeking an experienced geriatric psychiatrist for southern New Zealand World famous for whale watching, botanical gardens, snow skiing, golf, horse racing and so much more; any age is guaranteed

Psychiatry Adult jobs in "Austin area" - TX

Military hospital based in Texas is in urgent need for Adult Psychiatric inpatient coverage beginning as soon as possible, with 1 year optional extensions. Preferred candidate will be Board Certified

Psychiatry Adult jobs in "Northern" - CO

I am working with a client in Colorado that has a Psychiatry need 4/16/11-5/6/11. The schedule is Monday-Thursday working 10 hour shifts. Call would be telephone call only on Sunday and Tuesday nights.

Psychiatry Adult jobs in "Kentucky" - KY

Psychiatry locums coverage needed in Kentucky ASAP ongoing. -The practice is 100% inpatient. -VERY competitive pay -We cover malpractice, housing and lodging **If you are not available but you

Psychiatry Adult jobs in "Seattle" - WA

We have a need for Adult inpatient psychiatric coverage for a clinic north of Seattle Coverage starts May and runs through July. Avg. daily census is 8-11 on a 15-bed unit (all

Psychiatry Adult jobs in "Upstate" - NY

I am working with a client in Upstate New York that has an emergency Psychiatry need starting April 25, 2011 to May 16, 2011. This is an inpatient, 100% adult need. Call would be 1 weekend

Psychiatry Adult jobs in "Boston" - MA

Facility in the Boston area needs Psychiatric coverage ASAP for an ongoing period of time. Hours are 8-5, Mon thru Friday. On Call one day per week. Minimum length of assignment they will consider

Suicidal Thoughts and Behavior With Antidepressant Treatment: Reanalysis of the Randomized Placebo-Controlled Studies of Fluoxetine and Venlafaxine [Meta-analysis]

Context The US Food and Drug Administration issued a black box warning for antidepressants and suicidal thoughts and behavior in children and young adults. Objective To determine the short-term safety of antidepressants by standard assessments of suicidal thoughts and behavior in youth, adult, and geriatric populations and the mediating effect of changes in depressive symptoms. Data Sources All intent-to-treat person-level longitudinal data of major depressive disorder from 12 adult, 4 geriatric, and 4 youth randomized controlled trials of fluoxetine hydrochloride and 21 adult trials of venlafaxine hydrochloride. Study Selection All sponsor-conducted randomized controlled trials of fluoxetine and venlafaxine. Data Extraction The suicide items from the Children's Depression Rating Scale–Revised and the Hamilton Depression Rating Scale as well as adverse event reports of suicide attempts and suicide during active treatment were analyzed in 9185 patients (fluoxetine: 2635 adults, 960 geriatric patients, 708 youths; venlafaxine: 2421 adults with immediate-release venlafaxine and 2461 adults with extended-release venlafaxine) for a total of 53 260 person-week observations. Data Synthesis Suicidal thoughts and behavior decreased over time for adult and geriatric patients randomized to fluoxetine or venlafaxine compared with placebo, but no differences were found for youths. In adults, reduction in suicide ideation and attempts occurred through a reduction in depressive symptoms. In all age groups, severity of depression improved with medication and was significantly related to suicide ideation or behavior. Conclusions Fluoxetine and venlafaxine decreased suicidal thoughts and behavior for adult and geriatric patients. This protective effect is mediated by decreases in depressive symptoms with treatment. For youths, no significant effects of treatment on suicidal thoughts and behavior were found, although depression responded to treatment. No evidence of increased suicide risk was observed in youths receiving active medication. To our knowledge, this is the first research synthesis of suicidal thoughts and behavior in depressed patients treated with antidepressants that examined the mediating role of depressive symptoms using complete longitudinal person-level data from a large set of published and unpublished studies.

Influence of Patient Race and Ethnicity on Clinical Assessment in Patients With Affective Disorders [Original Article]

Context Rates of clinical diagnoses of schizophrenia in African American individuals appear to be elevated compared with other ethnic groups in the United States, contradicting population rates derived from epidemiologic surveys. Objective To determine whether African American individuals would continue to exhibit significantly higher rates of clinical diagnoses of schizophrenia, even after controlling for age, sex, income, site, and education, as well as the presence or absence of serious affective disorder, as determined by experts blinded to race and ethnicity. A secondary objective was to determine if a similar pattern occurred in Latino subjects. Design Ethnicity-blinded and -unblinded diagnostic assessments were obtained in 241 African American individuals (mean [SD] age, 34.3 [8.1] years; 57% women), 220 non-Latino white individuals (mean [SD] age, 32.7 [8.5] years; 53% women), and 149 Latino individuals (mean [SD] age, 33.5 [8.0] years; 58% women) at 6 US sites. Logistic regression models were used to determine whether elevated rates of schizophrenia in African American individuals would persist after controlling for various confounding variables including blinded expert consensus diagnoses of serious affective illness. Settings Six academic medical centers across the United States. Participants Six hundred ten psychiatric inpatients and outpatients. Main Outcome Measure Relative odds of unblinded clinical diagnoses of schizophrenia in African American compared with white individuals. Results A significant ethnicity/race effect (22 = 10.4, P = .01) was obtained when schizophrenia was narrowly defined, controlling for all other predictors. The odds ratio comparing African American with non-Latino white individuals was significant (odds ratio = 2.7; 95% CI, 1.5-5.1). Similar differences between African American and white individuals occurred when schizophrenia was more broadly defined (odds ratio = 2.5; 95% CI, 1.4-4.5). African American individuals did not differ significantly from white individuals in overall severity of manic and depressive symptoms but did evidence more severe psychosis. Conclusions African American individuals exhibited significantly higher rates of clinical diagnoses of schizophrenia than non-Latino white subjects, even after controlling for covariates such as serious affective disorder.

Impact of Smoking on Cognitive Decline in Early Old Age: The Whitehall II Cohort Study [Original Article]

Context Smoking is a possible risk factor for dementia, although its impact may have been underestimated in elderly populations because of the shorter life span of smokers. Objective To examine the association between smoking history and cognitive decline in the transition from midlife to old age. Design Cohort study. Setting The Whitehall II study. The first cognitive assessment was in 1997 to 1999, repeated over 2002 to 2004 and 2007 to 2009. Participants Data are from 5099 men and 2137 women in the Whitehall II study, mean age 56 years (range, 44-69 years) at the first cognitive assessment. Main Outcome Measures The cognitive test battery was composed of tests of memory, vocabulary, executive function (composed of 1 reasoning and 2 fluency tests), and a global cognitive score summarizing performance across all 5 tests. Smoking status was assessed over the entire study period. Linear mixed models were used to assess the association between smoking history and 10-year cognitive decline, expressed as z scores. Results In men, 10-year cognitive decline in all tests except vocabulary among never smokers ranged from a quarter to a third of the baseline standard deviation. Faster cognitive decline was observed among current smokers compared with never smokers in men (mean difference in 10-year decline in global cognition = –0.09 [95% CI, –0.15 to –0.03] and executive function = –0.11 [95% CI, –0.17 to –0.05]). Recent ex-smokers had greater decline in executive function (–0.08 [95% CI, –0.14 to –0.02]), while the decline in long-term ex-smokers was similar to that among never smokers. In analyses that additionally took dropout and death into account, these differences were 1.2 to 1.5 times larger. In women, cognitive decline did not vary as a function of smoking status. Conclusions Compared with never smokers, middle-aged male smokers experienced faster cognitive decline in global cognition and executive function. In ex-smokers with at least a 10-year cessation, there were no adverse effects on cognitive decline.

Differences in the Circuitry-Based Association of Copy Numbers and Gene Expression Between the Hippocampi of Patients With Schizophrenia and the Hippocampi of Patients With Bipolar Disorder [Original Article]

Context GAD67 regulation involves a network of genes implicated in schizophrenia and bipolar disorder. We have studied the copy number intensities of these genes in specific hippocampal subregions to clarify whether abnormalities of genomic integrity covary with gene expression in a circuitry-based manner. Objective To compare the copy number intensities of genes associated with GAD67 regulation in the stratum oriens of sectors CA3/2 and CA1 in patients with schizophrenia, patients with bipolar disorder, and healthy controls. Design Samples of sectors CA3/2 and CA1 were obtained from patients with schizophrenia, patients with bipolar disorder, and healthy controls. Genomic integrity was analyzed using microarrays, and the copy number intensities identified were correlated with the gene expression profile from a subset of these cases previously reported. Setting Harvard Brain Tissue Resource Center at McLean Hospital, Belmont, Massachusetts. Patients A total of 15 patients with schizophrenia, 15 patients with bipolar disorder, and 15 healthy controls. Main Outcome Measures The copy number intensities for 28 target genes were individually examined using single-nucleotide polymorphism microarrays and correlated with homologous messenger RNA (mRNA) fold changes. Results The copy number intensities examined using both microarrays and quantitative real-time polymerase chain reaction for the GAD67 gene were significantly decreased in sector CA3/2 of patients with schizophrenia and patients with bipolar disorder. Other genes associated with GAD67 regulation also showed changes in copy number intensities, and these changes were similar in magnitude and direction to those previously reported for mRNA fold changes in sector CA3/2 but not sector CA1. Moreover, the copy number intensities and mRNA fold changes were significantly correlated for both patients with schizophrenia (r = 0.649; P = .0003) and patients with bipolar disorder (r = 0.772; P = .0002) in sector CA3/2 but not in sector CA1. Conclusion Insertions and deletions of genomic DNA in -aminobutyric acid cells at a key locus of the hippocampal circuit are reflected in transcriptional changes in GAD67 regulation that are circuitry-based and diagnosis-specific.

Self-reported Attenuated Psychotic Symptoms as Forerunners of Severe Mental Disorders Later in Life [Original Article]

Context It has been suggested that attenuated psychotic symptoms (APSs) reported by people who do not have psychotic disorders signal risk for later severe mental illness. Objective To investigate this suggestion using follow-up assessments of hospitalization for clinical diagnoses of nonaffective psychotic and other psychiatric disorders. Design Longitudinal cohort study of self-reported APSs with outcome assessment of severe mental illness obtained through linkage with a national hospitalization case registry. Setting Israel. Participants A stratified full probability sample of 4914 persons aged 25 to 34 years who were screened for psychopathology in the 1980s. Main Outcome Measure Subsequent psychiatric hospitalization was ascertained using the psychiatric hospitalization registry, with a mean follow-up of 24 years. Results After removing subjects with diagnosable psychotic disorders at baseline, 57.2% of the remaining sample reported at least 1 weak (infrequent) APS and 14.3% reported at least 1 strong (frequent) APS in the year preceding the assessment. Self-reported APSs predicted risk of later hospitalization for nonaffective psychotic disorders, mostly during the 5 years after baseline (adjusted odds ratio = 4.31; 95% CI, 2.21-8.41; positive predictive value = 1.27%; population attributable risk fraction = 33%). Also, APSs increased the risk of later hospitalization for other psychiatric disorders, albeit to a lesser extent (adjusted odds ratio = 2.21; 95% CI, 1.02-4.82). Conclusions Self-reported APSs signal risk for later nonaffective psychotic disorders but are not clinically useful as predictors. The difference between these population-based data and the high-risk literature in terms of the positive predictive value (1% vs 10%, respectively) and the time window of transition (5 years vs 12 months, respectively) can be attributed to the selective enrichment strategies that produce high-risk samples.

Elevated Prefrontal Cortex {gamma}-Aminobutyric Acid and Glutamate-Glutamine Levels in Schizophrenia Measured In Vivo With Proton Magnetic Resonance Spectroscopy [Original Article]

Context Postmortem studies have found evidence of -aminobutyric acid (GABA) deficits in fast-spiking, parvalbumin-positive interneurons in the prefrontal cortex in schizophrenia. Magnetic resonance spectroscopy studies in unmedicated patients have reported glutamine or glutamate-glutamine (Glx) elevations in this region. Abnormalities in these transmitters are thought to play a role in cognitive impairments in the illness. Objective To measure GABA and Glx levels in vivo in 2 prefrontal brain regions in unmedicated and medicated patients with schizophrenia and healthy controls. Design Case-control study. Setting Inpatient psychiatric research unit and associated outpatient clinic. Participants Sixteen unmedicated patients with schizophrenia, 16 medicated patients, and 22 healthy controls matched for age, sex, ethnicity, parental socioeconomic status, and cigarette smoking. Methods Proton magnetic resonance spectroscopy with a 3-T system and the J-edited spin-echo difference method. The GABA and Glx levels were measured in the dorsolateral and medial prefrontal cortex and normalized to the simultaneously acquired water signal. Working memory performance was assessed in all subjects. Main Outcome Measures The GABA and Glx concentrations determined by proton magnetic resonance spectroscopy. Results In the medial prefrontal cortex region, 30% elevations were found in GABA (P = .02) and Glx (P = .03) levels in unmedicated patients compared with controls. There were no alterations in the medicated patients or in either group in the dorsolateral prefrontal cortex. Both regions showed correlations between GABA and Glx levels in patients and controls. No correlations with working memory performance were found. Conclusions To our knowledge, this study presents the first GABA concentration measurements in unmedicated patients with schizophrenia, who showed elevations in both GABA and Glx levels in the medial prefrontal cortex but not the dorsolateral prefrontal cortex. Medicated patients did not show these elevations, suggesting possible normalization of levels with antipsychotic medication. The Glx elevations agree with prior magnetic resonance spectroscopy literature, but GABA elevations were unexpected and suggest possible involvement of classes of interneurons not found to show impairments in postmortem studies.

A Randomized Controlled Trial of Risperidone, Lithium, or Divalproex Sodium for Initial Treatment of Bipolar I Disorder, Manic or Mixed Phase, in Children and Adolescents [Original Article]

Context There was a paucity of comparative pharmacological research for initial treatment of bipolar I disorder, manic or mixed phase, in children and adolescents. Objective To investigate which medication to administer first to antimanic medication–naive subjects. Design, Setting, and Participants The Treatment of Early Age Mania (TEAM) study recruited 6- to 15-year-old children and adolescents with DSM-IV bipolar I disorder (manic or mixed phase) at 5 US sites from 2003 to 2008 into a controlled, randomized, no-patient-choice, 8-week protocol. Blinded, independent evaluators conducted all baseline and end-point assessments. Interventions Subjects received a titrated schedule of lithium, divalproex sodium, or risperidone. Medications were increased weekly only if there was inadequate response, and no dose-limiting adverse effects, to maximum doses of lithium carbonate (1.1-1.3 mEq/L), divalproex sodium (111-125 μg/mL), and risperidone (4-6 mg). Main Outcome Measures Primary outcome measures were the Clinical Global Impressions for Bipolar Illness Improvement–Mania and the Modified Side Effects Form for Children and Adolescents. Results There were 279 antimanic medication–naive subjects (mean [SD] age, 10.1 [2.8] years; 50.2% female) who had the following characteristics: 100% elated mood and/or grandiosity, 77.1% psychosis, 97.5% mixed mania, 99.3% daily rapid cycling, and mean (SD) mania duration of 4.9 (2.5) years. The mean (SD) titrated lithium level was 1.09 (0.34) mEq/L, and the mean (SD) divalproex sodium level was 113.6 (23.0) μg/mL. The mean (SD) titrated risperidone dose was 2.57 (1.21) mg. Higher response rates occurred with risperidone vs lithium (68.5% vs 35.6%; 21 = 16.9, P < .001) and vs divalproex sodium (68.5% vs 24.0%; 21 = 28.3, P < .001). Response to lithium vs divalproex sodium did not differ. The discontinuation rate was higher for lithium than for risperidone (21 = 6.4, P = .011). Increased weight gain, body mass index, and prolactin level occurred with risperidone vs lithium (F1,212 = 45.5, P < .001; F1,212 = 39.1, P < .001; and F1,213 = 191.4, P < .001, respectively) and vs divalproex sodium (F1,212 = 34.7, P < .001; F1,212 = 45.3, P < .001; and F1,213 = 209.4, P < .001, respectively). The thyrotropin level increased in subjects taking lithium (t62 = 11.3, P < .001). Conclusions Risperidone was more efficacious than lithium or divalproex sodium for the initial treatment of childhood mania but had potentially serious metabolic effects. Trial Registration clinicaltrials.gov Identifier: NCT00057681

Prevalence, Persistence, and Sociodemographic Correlates of DSM-IV Disorders in the National Comorbidity Survey Replication Adolescent Supplement [Original Article]

Context Community epidemiological data on the prevalence and correlates of adolescent mental disorders are needed for policy planning purposes. Only limited data of this sort are available. Objective To present estimates of 12-month and 30-day prevalence, persistence (12-month prevalence among lifetime cases and 30-day prevalence among 12-month cases), and sociodemographic correlates of commonly occurring DSM-IV disorders among adolescents in the National Comorbidity Survey Replication Adolescent Supplement. Design The National Comorbidity Survey Replication Adolescent Supplement is a US national survey of DSM-IV anxiety, mood, behavior, and substance disorders among US adolescents based on face-to-face interviews in the homes of respondents with supplemental parent questionnaires. Setting Dual-frame household and school samples of US adolescents. Participants A total of 10 148 adolescents aged 13 to 17 years (interviews) and 1 parent of each adolescent (questionnaires). Main Outcome Measures The DSM-IV disorders assessed with the World Health Organization Composite International Diagnostic Interview and validated with blinded clinical interviews based on the Schedule for Affective Disorders and Schizophrenia for School-Age Children. Good concordance (area under the receiver operating characteristic curve ≥0.80) was found between Composite International Diagnostic Interview and Schedule for Affective Disorders and Schizophrenia for School-Age Children diagnoses. Results The prevalence estimates of any DSM-IV disorder are 40.3% at 12 months (79.5% of lifetime cases) and 23.4% at 30 days (57.9% of 12-month cases). Anxiety disorders are the most common class of disorders, followed by behavior, mood, and substance disorders. Although relative disorder prevalence is quite stable over time, 30-day to 12-month prevalence ratios are higher for anxiety and behavior disorders than mood or substance disorders, suggesting that the former are more chronic than the latter. The 30-day to 12-month prevalence ratios are generally lower than the 12-month to lifetime ratios, suggesting that disorder persistence is due more to episode recurrence than to chronicity. Sociodemographic correlates are largely consistent with previous studies. Conclusions Among US adolescents, DSM-IV disorders are highly prevalent and persistent. Persistence is higher for adolescents than among adults and appears to be due more to recurrence than chronicity of child-adolescent onset disorders.

Psychiatric Disorders With Postpartum Onset: Possible Early Manifestations of Bipolar Affective Disorders [Original Article]

Context Childbirth has an important influence on the onset and course of bipolar affective disorder, and it is well established that there may be a delay of many years before receiving a diagnosis of bipolar disorder following an initial episode of psychiatric illness. Objective To study to what extent psychiatric disorders with postpartum onset are early manifestations of an underlying bipolar affective disorder. Design Survival analyses were performed in a register-based cohort study linking information from the Danish Civil Registration System and the Danish Psychiatric Central Register. Setting Denmark. Participants A total of 120 378 women with a first-time psychiatric inpatient or outpatient contact with any type of mental disorder excluding bipolar affective disorder. Main Outcome Measures Each woman was followed up individually from the day of discharge, with the outcome of interest being an inpatient or outpatient contact during the follow-up period with a first-time diagnosis of bipolar affective disorder. Results A total of 3062 women were readmitted or had an outpatient contact with bipolar affective disorder diagnoses. A postpartum onset of symptoms within 0 to 14 days after delivery predicted subsequent conversion to bipolar disorder (relative risk = 4.26; 95% CI =3.11-5.85). Approximately 14% of women with first-time psychiatric contacts during the first postpartum month converted to a bipolar diagnosis within the 15-year follow-up period compared with 4% of women with a first psychiatric contact not related to childbirth. Postpartum inpatient admissions were also associated with higher conversion rates to bipolar disorder than outpatient contacts (relative risk = 2.16; 95% CI = 1.27-3.66). Conclusions A psychiatric episode in the immediate postpartum period significantly predicted conversion to bipolar affective disorder during the follow-up period. Results indicate that the presentation of mental illness in the early postpartum period is a marker of possible underlying bipolarity.

Evidence for Chronically Altered Serotonin Function in the Cerebral Cortex of Female 3,4-Methylenedioxymethamphetamine Polydrug Users [Original Article]

Context MDMA (3,4-methylenedioxymethamphetamine, also popularly known as "ecstasy") is a popular recreational drug that produces loss of serotonin axons in animal models. Whether MDMA produces chronic reductions in serotonin signaling in humans remains controversial. Objective To determine whether MDMA use is associated with chronic reductions in serotonin signaling in the cerebral cortex of women as reflected by increased serotonin2A receptor levels. Design Cross-sectional case-control study comparing serotonin2A receptor levels in abstinent female MDMA polydrug users with those in women who did not use MDMA (within-group design assessing the association of lifetime MDMA use and serotonin2A receptors). Case participants were abstinent from MDMA use for at least 90 days as verified by analysis of hair samples. The serotonin2A receptor levels in the cerebral cortex were determined using serotonin2A-specific positron emission tomography with radioligand fluorine 18–labeled setoperone as the tracer. Setting Academic medical center research laboratory. Participants A total of 14 female MDMA users and 10 women who did not use MDMA (controls). The main exclusion criteria were nondrug-related DSM-IV Axis I psychiatric disorders and general medical illness. Main Outcome Measures Cortical serotonin2A receptor nondisplaceable binding potential (serotonin2ABPND). Results MDMA users had increased serotonin2ABPND in occipital-parietal (19.7%), temporal (20.5%), occipitotemporal-parietal (18.3%), frontal (16.6%), and frontoparietal (18.5%) regions (corrected P < .05). Lifetime MDMA use was positively associated with serotonin2ABPND in frontoparietal (β = 0.665; P = .007), occipitotemporal (β = 0.798; P = .002), frontolimbic (β = 0.634; P = .02), and frontal (β = 0.691; P = .008) regions. In contrast, there were no regions in which MDMA use was inversely associated with receptor levels. There were no statistically significant effects of the duration of MDMA abstinence on serotonin2ABPND. Conclusions The recreational use of MDMA is associated with long-lasting increases in serotonin2A receptor density. Serotonin2A receptor levels correlate positively with lifetime MDMA use and do not decrease with abstinence. These results suggest that MDMA use produces chronic serotonin neurotoxicity in humans. Given the broad role of serotonin in human brain function, the possibility for therapeutic MDMA use, and the widespread recreational popularity of this drug, these results have critical public health implications.

Association of Depression With Increased Risk of Dementia in Patients With Type 2 Diabetes: The Diabetes and Aging Study [Original Article]

Context Although depression is a risk factor for dementia in the general population, its association with dementia among patients with diabetes mellitus has not been well studied. Objective To determine whether comorbid depression in patients with type 2 diabetes increases the risk of development of dementia. Design The Diabetes and Aging Study was a cohort investigation that surveyed a racially/ethnically stratified random sample of patients with type 2 diabetes. Setting A large, integrated, nonprofit managed care setting in Northern California. Participants A sample of 19 239 diabetes registry members 30 to 75 years of age. Main Outcome Measures The Patient Health Questionnaire 8, International Classification of Diseases, Ninth Revision (ICD-9) diagnoses of depression, and/or antidepressant prescriptions in the 12 months prior to baseline were used to identify prevalent cases of depression. Clinically recognized dementia was identified among subjects with no prior ICD-9 Clinical Modification (ICD-9-CM) diagnoses of dementia. To exclude the possibility that depression was a prodrome of dementia, dementia diagnoses were only based on ICD-9-CM diagnoses identified in years 3 to 5 postbaseline. The risk of dementia for patients with depression and diabetes relative to patients with diabetes alone was estimated using Cox proportional hazard regression models that adjusted for sociodemographic, clinical, and health risk factors and health use. Results During the 3- to 5-year period, 80 of 3766 patients (2.1%) with comorbid depression and diabetes (incidence rate of 5.5 per 1000 person-years) vs 158 of 15 473 patients (1.0%) with diabetes alone (incidence rate of 2.6 per 1000 person-years) had 1 or more ICD-9-CM diagnoses of dementia. Patients with comorbid depression had a 100% increased risk of dementia during the 3 to 5 years postbaseline (adjusted hazard ratio, 2.02; 95% confidence interval, 1.73-2.35). Conclusion Depression in patients with diabetes was associated with a substantively increased risk for development of dementia compared with those with diabetes alone.

Epigenetic Signatures of Autism: Trimethylated H3K4 Landscapes in Prefrontal Neurons [Original Article]

Context Neuronal dysfunction in cerebral cortex and other brain regions could contribute to the cognitive and behavioral defects in autism. Objective To characterize epigenetic signatures of autism in prefrontal cortex neurons. Design We performed fluorescence-activated sorting and separation of neuronal and nonneuronal nuclei from postmortem prefrontal cortex, digested the chromatin with micrococcal nuclease, and deeply sequenced the DNA from the mononucleosomes with trimethylated H3K4 (H3K4me3), a histone mark associated with transcriptional regulation. Approximately 15 billion base pairs of H3K4me3-enriched sequences were collected from 32 brains. Setting Academic medical center. Participants A total of 16 subjects diagnosed as having autism and 16 control subjects ranging in age from 0.5 to 70 years. Main Outcome Measures Identification of genomic loci showing autism-associated H3K4me3 changes in prefrontal cortex neurons. Results Subjects with autism showed no evidence for generalized disruption of the developmentally regulated remodeling of the H3K4me3 landscape that defines normal prefrontal cortex neurons in early infancy. However, excess spreading of H3K4me3 from the transcription start sites into downstream gene bodies and upstream promoters was observed specifically in neuronal chromatin from 4 of 16 autism cases but not in controls. Variable subsets of autism cases exhibit altered H3K4me3 peaks at numerous genes regulating neuronal connectivity, social behaviors, and cognition, often in conjunction with altered expression of the corresponding transcripts. Autism-associated H3K4me3 peaks were significantly enriched in genes and loci implicated in neurodevelopmental diseases. Conclusions Prefrontal cortex neurons from subjects with autism show changes in chromatin structures at hundreds of loci genome-wide, revealing considerable overlap between genetic and epigenetic risk maps of developmental brain disorders.

A Multisite Study of the Clinical Diagnosis of Different Autism Spectrum Disorders [Original Article]

Context Best-estimate clinical diagnoses of specific autism spectrum disorders (autistic disorder, pervasive developmental disorder–not otherwise specified, and Asperger syndrome) have been used as the diagnostic gold standard, even when information from standardized instruments is available. Objective To determine whether the relationships between behavioral phenotypes and clinical diagnoses of different autism spectrum disorders vary across 12 university-based sites. Design Multisite observational study collecting clinical phenotype data (diagnostic, developmental, and demographic) for genetic research. Classification trees were used to identify characteristics that predicted diagnosis across and within sites. Setting Participants were recruited through 12 university-based autism service providers into a genetic study of autism. Participants A total of 2102 probands (1814 male probands) between 4 and 18 years of age (mean [SD] age, 8.93 [3.5] years) who met autism spectrum criteria on the Autism Diagnostic Interview–Revised and the Autism Diagnostic Observation Schedule and who had a clinical diagnosis of an autism spectrum disorder. Main Outcome Measure Best-estimate clinical diagnoses predicted by standardized scores from diagnostic, cognitive, and behavioral measures. Results Although distributions of scores on standardized measures were similar across sites, significant site differences emerged in best-estimate clinical diagnoses of specific autism spectrum disorders. Relationships between clinical diagnoses and standardized scores, particularly verbal IQ, language level, and core diagnostic features, varied across sites in weighting of information and cutoffs. Conclusions Clinical distinctions among categorical diagnostic subtypes of autism spectrum disorders were not reliable even across sites with well-documented fidelity using standardized diagnostic instruments. Results support the move from existing subgroupings of autism spectrum disorders to dimensional descriptions of core features of social affect and fixated, repetitive behaviors, together with characteristics such as language level and cognitive function.

Testing Standard and Modular Designs for Psychotherapy Treating Depression, Anxiety, and Conduct Problems in Youth: A Randomized Effectiveness Trial [Original Article]

Context Decades of randomized controlled trials have produced separate evidence-based treatments for depression, anxiety, and conduct problems in youth, but these treatments are not often used in clinical practice, and they produce mixed results in trials with the comorbid, complex youths seen in practice. An integrative, modular redesign may help. Objective Standard/separate and modular/integrated arrangements of evidence-based treatments for depression, anxiety, and conduct problems in youth were compared with usual care treatment, with the modular design permitting a multidisorder focus and a flexible application of treatment procedures. Design Randomized effectiveness trial. Setting Ten outpatient clinical service organizations in Massachusetts and Hawaii. Participants A total of 84 community clinicians were randomly assigned to 1 of 3 conditions for the treatment of 174 clinically referred youths who were 7 to 13 years of age (70% of these youths were boys, and 45% were white). The study was conducted during the period from January 12, 2005 to May 8, 2009. Interventions Standard manual treatment (59 youths [34% of the sample]; cognitive behavioral therapy for depression, cognitive behavioral therapy for anxiety, and behavioral parent training for conduct problems), modular treatment (62 youths [36%]; integrating the procedures of the 3 separate treatments), and usual care (53 youths [30%]). Main Outcome Measures Outcomes were assessed using weekly youth and parent assessments. These assessments relied on a standardized Brief Problem Checklist and a patient-generated Top Problems Assessment (ie, the severity ratings on the problems that the youths and parents had identified as most important). We also conducted a standardized diagnostic assessment before and after treatment. Results Mixed effects regression analyses showed that modular treatment produced significantly steeper trajectories of improvement than usual care and standard treatment on multiple Brief Problem Checklist and Top Problems Assessment measures. Youths receiving modular treatment also had significantly fewer diagnoses than youths receiving usual care after treatment. In contrast, outcomes of standard manual treatment did not differ significantly from outcomes of usual care. Conclusions The modular approach outperformed usual care and standard evidence-based treatments on multiple clinical outcome measures. The modular approach may be a promising way to build on the strengths of evidence-based treatments, improving their utility and effectiveness with referred youths in clinical practice settings. Trial Registration clinicaltrials.gov Identifier: NCT01178554

About This Journal [About This Journal]

This Month in Archives of General Psychiatry [This Month in Archives of General Psychiatry]

Washington Crossing the Delaware [Art and Images in Psychiatry]

Cognitive Therapy for Negative Symptoms of Schizophrenia [Editorial]

Randomized Trial to Evaluate the Efficacy of Cognitive Therapy for Low-Functioning Patients With Schizophrenia [Original Article]

Context Low-functioning patients with chronic schizophrenia have high direct treatment costs and indirect costs incurred due to lost employment and productivity and have a low quality of life; antipsychotic medications and psychosocial interventions have shown limited efficacy to promote improved functional outcomes. Objective To determine the efficacy of an 18-month recovery-oriented cognitive therapy program to improve psychosocial functioning and negative symptoms (avolition-apathy, anhedonia-asociality) in low-functioning patients with schizophrenia. Design, Setting, and Participants A single-center, 18-month, randomized, single-blind, parallel group trial enrolled 60 low-functioning, neurocognitively impaired patients with schizophrenia (mean age, 38.4 years; 33.3% female; 65.0% African American). Interventions Cognitive therapy plus standard treatment vs standard treatment alone. Main Outcome Measures The primary outcome measure was the Global Assessment Scale score at 18 months after randomization. The secondary outcomes were scores on the Scale for the Assessment of Negative Symptoms and the Scale for the Assessment of Positive Symptoms at 18 months after randomization. Results Patients treated with cognitive therapy showed a clinically significant mean improvement in global functioning from baseline to 18 months that was greater than the improvement seen with standard treatment (within-group Cohen d, 1.36 vs 0.06, respectively; adjusted mean [SE], 58.3 [3.30] vs 47.9 [3.60], respectively; P = .03; between-group d = 0.56). Patients receiving cognitive therapy as compared with those receiving standard treatment also showed a greater mean reduction in avolition-apathy (adjusted mean [SE], 1.66 [0.31] vs 2.81 [0.34], respectively; P = .01; between-group d = –0.66) and positive symptoms (hallucinations, delusions, disorganization) (adjusted mean [SE], 9.4 [3.3] vs 18.2 [3.8], respectively; P = .04; between-group d = –0.46) at 18 months. Age was controlled in the analyses, and there were no meaningful group differences in baseline antipsychotic medications (class or dosage) or in medication changes during the course of the trial. Conclusion Cognitive therapy can be successful in promoting clinically meaningful improvements in functional outcome, motivation, and positive symptoms in low-functioning patients with significant cognitive impairment. Trial Registration clinicaltrials.gov Identifier: NCT00350883

Negative Symptoms and the Failure to Represent the Expected Reward Value of Actions: Behavioral and Computational Modeling Evidence [Original Article]

Context Negative symptoms are a core feature of schizophrenia, but their pathogenesis remains unclear. Negative symptoms are defined by the absence of normal function. However, there must be a productive mechanism that leads to this absence. Objective To test a reinforcement learning account suggesting that negative symptoms result from a failure in the representation of the expected value of rewards coupled with preserved loss-avoidance learning. Design Participants performed a probabilistic reinforcement learning paradigm involving stimulus pairs in which choices resulted in reward or in loss avoidance. Following training, participants indicated their valuation of the stimuli in a transfer test phase. Computational modeling was used to distinguish between alternative accounts of the data. Setting A tertiary care research outpatient clinic. Patients In total, 47 clinically stable patients with a diagnosis of schizophrenia or schizoaffective disorder and 28 healthy volunteers participated in the study. Patients were divided into a high-negative symptom group and a low-negative symptom group. Main Outcome Measures The number of choices leading to reward or loss avoidance, as well as performance in the transfer test phase. Quantitative fits from 3 different models were examined. Results Patients in the high-negative symptom group demonstrated impaired learning from rewards but intact loss-avoidance learning and failed to distinguish rewarding stimuli from loss-avoiding stimuli in the transfer test phase. Model fits revealed that patients in the high-negative symptom group were better characterized by an "actor-critic" model, learning stimulus-response associations, whereas control subjects and patients in the low-negative symptom group incorporated expected value of their actions ("Q learning") into the selection process. Conclusions Negative symptoms in schizophrenia are associated with a specific reinforcement learning abnormality: patients with high-negative symptoms do not represent the expected value of rewards when making decisions but learn to avoid punishments through the use of prediction errors. This computational framework offers the potential to understand negative symptoms at a mechanistic level.

Anterior Cingulate Cortex {gamma}-Aminobutyric Acid in Depressed Adolescents: Relationship to Anhedonia [Original Article]

Context Anhedonia, a core symptom of major depressive disorder (MDD) and highly variable among adolescents with MDD, may involve alterations in the major inhibitory amino acid neurotransmitter system of -aminobutyric acid (GABA). Objective To test whether anterior cingulate cortex (ACC) GABA levels, measured by proton magnetic resonance spectroscopy, are decreased in adolescents with MDD. The associations of GABA alterations with the presence and severity of anhedonia were explored. Design Case-control, cross-sectional study using single-voxel proton magnetic resonance spectroscopy at 3 T. Setting Two clinical research divisions at 2 teaching hospitals. Participants Twenty psychotropic medication-free adolescents with MDD (10 anhedonic, 12 female, aged 12-19 years) with episode duration of 8 weeks or more and 21 control subjects group matched for sex and age. Main Outcome Measures Anterior cingulate cortex GABA levels expressed as ratios relative to unsuppressed voxel tissue water (w) and anhedonia scores expressed as a continuous variable. Results Compared with control subjects, adolescents with MDD had significantly decreased ACC GABA/w (t = 3.2; P < .003). When subjects with MDD were categorized based on the presence of anhedonia, only anhedonic patients had decreased GABA/w levels compared with control subjects (t = 4.08; P < .001; PTukey < .001). Anterior cingulate cortex GABA/w levels were negatively correlated with anhedonia scores for the whole MDD group (r = –0.50; P = .02), as well as for the entire participant sample including the control subjects (r = –0.54; P < .001). Anterior cingulate cortex white matter was also significantly decreased in adolescents with MDD compared with controls (P = .04). Conclusions These findings suggest that GABA, the major inhibitory neurotransmitter in the brain, may be implicated in adolescent MDD and, more specifically, in those with anhedonia. In addition, use of a continuous rather than categorical scale of anhedonia, as in the present study, may permit greater specificity in evaluating this important clinical feature.

Subcallosal Cingulate Deep Brain Stimulation for Treatment-Resistant Unipolar and Bipolar Depression [Original Article]

Context Deep brain stimulation (DBS) may be an effective intervention for treatment-resistant depression (TRD), but available data are limited. Objective To assess the efficacy and safety of subcallosal cingulate DBS in patients with TRD with either major depressive disorder (MDD) or bipolar II disorder (BP). Design Open-label trial with a sham lead-in phase. Setting Academic medical center. Patients Men and women aged 18 to 70 years with a moderate-to-severe major depressive episode after at least 4 adequate antidepressant treatments. Ten patients with MDD and 7 with BP were enrolled from a total of 323 patients screened. Intervention Deep brain stimulation electrodes were implanted bilaterally in the subcallosal cingulate white matter. Patients received single-blind sham stimulation for 4 weeks followed by active stimulation for 24 weeks. Patients then entered a single-blind discontinuation phase; this phase was stopped after the first 3 patients because of ethical concerns. Patients were evaluated for up to 2 years after the onset of active stimulation. Main Outcome Measures Change in depression severity and functioning over time, and response and remission rates after 24 weeks were the primary efficacy end points; secondary efficacy end points were 1 year and 2 years of active stimulation. Results A significant decrease in depression and increase in function were associated with chronic stimulation. Remission and response were seen in 3 patients (18%) and 7 (41%) after 24 weeks (n = 17), 5 (36%) and 5 (36%) after 1 year (n = 14), and 7 (58%) and 11 (92%) after 2 years (n = 12) of active stimulation. No patient achieving remission experienced a spontaneous relapse. Efficacy was similar for patients with MDD and those with BP. Chronic DBS was safe and well tolerated, and no hypomanic or manic episodes occurred. A modest sham stimulation effect was found, likely due to a decrease in depression after the surgical intervention but prior to entering the sham phase. Conclusions The findings of this study support the long-term safety and antidepressant efficacy of subcallosal cingulate DBS for TRD and suggest equivalent safety and efficacy for TRD in patients with BP. Trial Registration clinicaltrials.gov Identifier: NCT00367003

First-Time First-Trimester Induced Abortion and Risk of Readmission to a Psychiatric Hospital in Women With a History of Treated Mental Disorder [Original Article]

Context Mental health problems are associated with women's reproductive decisions and predict poor mental health outcomes after abortion and childbirth. Objectives To study whether having a first-trimester induced abortion influenced the risk of psychiatric readmission and compare findings with readmission risk in women with mental disorders giving birth. Design Survival analyses were performed in a population-based cohort study merging data from the Danish Civil Registration System, the Danish Psychiatric Central Register, and the Danish National Hospital Register from January 1,1994, to December 31, 2007. Setting Denmark. Participants All women born in Denmark between 1962 and 1992 with a record of 1 or more psychiatric admissions at least 9 months before a first-time first-trimester induced abortion or childbirth. Main Outcome Measure Readmission at a psychiatric hospital with any type of mental disorder from 9 months before to 12 months after a first-time first-trimester induced abortion or childbirth. Results Relative risk (RR) for readmission risk 9 to 0 months before a first-trimester induced abortion was 0.95 (95% CI, 0.73-1.23) compared with the first year after the abortion. This contrasts with a reduced risk of readmission before childbirth (RR, 0.56; 95% CI, 0.42-0.75) compared with the first year post partum. Proximity to previous psychiatric admission in particular predicted rehospitalization risks in both the abortion and the childbirth group. Conclusions Risk of readmission is similar before and after first-time first-trimester abortion, contrasting with a marked increased in risk of readmission post partum. We speculate that recent psychiatric episodes may influence women's decisions to have an induced abortion; however, this decision does not appear to influence the illness course in women with a history of treated mental disorders.

Prevention of Posttraumatic Stress Disorder by Early Treatment: Results From the Jerusalem Trauma Outreach and Prevention Study [Original Article]

Context Preventing posttraumatic stress disorder (PTSD) is a pressing public health need. Objectives To compare early and delayed exposure-based, cognitive, and pharmacological interventions for preventing PTSD. Design Equipoise-stratified randomized controlled study. Setting Hadassah Hospital unselectively receives trauma survivors from Jerusalem and vicinity. Participants Consecutively admitted survivors of traumatic events were assessed by use of structured telephone interviews a mean (SD) 9.61 (3.91) days after the traumatic event. Survivors with symptoms of acute stress disorder were referred for clinical assessment. Survivors who met PTSD symptom criteria during the clinical assessment were invited to receive treatment. Interventions Twelve weekly sessions of prolonged exposure (PE; n = 63), or cognitive therapy (CT; n = 40), or double blind treatment with 2 daily tablets of either escitalopram (10 mg) or placebo (selective serotonin reuptake inhibitor/placebo; n = 46), or 12 weeks in a waiting list group (n = 93). Treatment started a mean (SD) 29.8 (5.7) days after the traumatic event. Waiting list participants with PTSD after 12 weeks received PE a mean (SD) 151.8 (42.4) days after the traumatic event (delayed PE). Main Outcome Measure Proportion of participants with PTSD after treatment, as determined by the use of the Clinician-Administered PTSD Scale (CAPS) 5 and 9 months after the traumatic event. Treatment assignment and attendance were concealed from the clinicians who used the CAPS. Results At 5 months, 21.6% of participants who received PE and 57.1% of comparable participants on the waiting list had PTSD (odds ratio [OR], 0.21 [95% CI, 0.09-0.46]). At 5 months, 20.0% of participants who received CT and 58.7% of comparable participants on the waiting list had PTSD (OR, 0.18 [CI, 0.06-0.48]). The PE group did not differ from the CT group with regard to PTSD outcome (OR, 0.87 [95% CI, 0.29-2.62]). The PTSD prevalence rates did not differ between the escitalopram and placebo subgroups (61.9% vs 55.6%; OR, 0.77 [95% CI, 0.21-2.77]). At 9 months, 20.8% of participants who received PE and 21.4% of participants on the waiting list had PTSD (OR, 1.04 [95% CI, 0.40-2.67]). Participants with partial PTSD before treatment onset did similarly well with and without treatment. Conclusions Prolonged exposure, CT, and delayed PE effectively prevent chronic PTSD in recent survivors. The lack of improvement from treatment with escitalopram requires further evaluation. Trauma-focused clinical interventions have no added benefit to survivors with subthreshold PTSD symptoms. Trial Registration clinicaltrials.gov Identifier: NCT00146900

Altered Neural Reward Representations in Pathological Gamblers Revealed by Delay and Probability Discounting [Original Article]

Context The neural basis of excessive delay discounting and reduced risk sensitivity of pathological gamblers with a particular focus on subjective neural reward representations has not been previously examined. Objective To examine how pathological gamblers represent subjective reward value at a neural level and how this is affected by gambling severity. Design Model-based functional magnetic resonance imaging study with patients and control subjects. Setting Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf. Participants Participants were recruited from the local community by advertisement and through self-help groups. A sample of 16 pathological gamblers (according to the DSM-IV definition) was matched by age, sex, smoking status, income, educational level, and handedness to 16 healthy controls. Results Pathological gamblers showed increased discounting of delayed rewards and a trend toward decreased discounting of probabilistic rewards compared with matched controls. At the neural level, a significant group x condition interaction indicated that reward representations in the gamblers were modulated in a condition-specific manner, such that they exhibited increased (delay discounting) and decreased (probability discounting) neural value correlations in the reward system. In addition, throughout the reward system, neuronal value signals for delayed rewards were negatively correlated with gambling severity. Conclusions The results extend previous reports of a generally hypoactive reward system in pathological gamblers by showing that, even when subjective reward valuation is accounted for, gamblers still show altered reward representations. Furthermore, results point toward a gradual degradation of mesolimbic reward representations for delayed rewards during the course of pathological gambling.

Assessment of Pedophilia Using Hemodynamic Brain Response to Sexual Stimuli [Original Article]

Context Accurately assessing sexual preference is important in the treatment of child sex offenders. Phallometry is the standard method to identify sexual preference; however, this measure has been criticized for its intrusiveness and limited reliability. Objective To evaluate whether spatial response pattern to sexual stimuli as revealed by a change in the blood oxygen level–dependent signal facilitates the identification of pedophiles. Design During functional magnetic resonance imaging, pedophilic and nonpedophilic participants were briefly exposed to same- and opposite-sex images of nude children and adults. We calculated differences in blood oxygen level–dependent signals to child and adult sexual stimuli for each participant. The corresponding contrast images were entered into a group analysis to calculate whole-brain difference maps between groups. We calculated an expression value that corresponded to the group result for each participant. These expression values were submitted to 2 different classification algorithms: Fisher linear discriminant analysis and -nearest neighbor analysis. This classification procedure was cross-validated using the leave-one-out method. Setting Section of Sexual Medicine, Medical School, Christian Albrechts University of Kiel, Kiel, Germany. Participants We recruited 24 participants with pedophilia who were sexually attracted to either prepubescent girls (n = 11) or prepubescent boys (n = 13) and 32 healthy male controls who were sexually attracted to either adult women (n = 18) or adult men (n = 14). Main Outcome Measures Sensitivity and specificity scores of the 2 classification algorithms. Results The highest classification accuracy was achieved by Fisher linear discriminant analysis, which showed a mean accuracy of 95% (100% specificity, 88% sensitivity). Conclusions Functional brain response patterns to sexual stimuli contain sufficient information to identify pedophiles with high accuracy. The automatic classification of these patterns is a promising objective tool to clinically diagnose pedophilia.

Brain Anatomy and Its Relationship to Behavior in Adults With Autism Spectrum Disorder: A Multicenter Magnetic Resonance Imaging Study [Original Article]

Context There is consensus that autism spectrum disorder (ASD) is accompanied by differences in neuroanatomy. However, the neural substrates of ASD during adulthood, as well as how these relate to behavioral variation, remain poorly understood. Objective To identify brain regions and systems associated with ASD in a large, well-characterized sample of adults. Design Multicenter case-control design using quantitative magnetic resonance imaging. Setting Medical Research Council UK Autism Imaging Multicentre Study (MRC AIMS), with sites comprising the Institute of Psychiatry, Kings College London; the Autism Research Centre, University of Cambridge; and the Autism Research Group, University of Oxford. Participants Eighty-nine men with ASD and 89 male control participants who did not differ significantly in mean age (26 and 28 years, respectively) and full-scale IQ (110 and 113, respectively). Main Outcome Measures (1) Between-group differences in regional neuroanatomy assessed by voxel-based morphometry and (2) distributed neural systems maximally correlated with ASD, as identified by partial least-squares analysis. Results Adults with ASD did not differ significantly from the controls in overall brain volume, confirming the results of smaller studies of individuals in this age group without intellectual disability. However, voxelwise comparison between groups revealed that individuals with ASD had significantly increased gray matter volume in the anterior temporal and dorsolateral prefrontal regions and significant reductions in the occipital and medial parietal regions compared with controls. These regional differences in neuroanatomy were significantly correlated with the severity of specific autistic symptoms. The large-scale neuroanatomic networks maximally correlated with ASD identified by partial least-squares analysis included the regions identified by voxel-based analysis, as well as the cerebellum, basal ganglia, amygdala, inferior parietal lobe, cingulate cortex, and various medial, orbital, and lateral prefrontal regions. We also observed spatially distributed reductions in white matter volume in participants with ASD. Conclusions Adults with ASD have distributed differences in brain anatomy and connectivity that are associated with specific autistic features and traits. These results are compatible with the concept of autism as a syndrome characterized by atypical neural "connectivity."

Error in Text in: Chauvet Cave: The Panel of Horses [Correction]

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Psychiatry Opportunity Located 1 hour 45 Minutes Northwest of Atlanta Hospital is seeking someone that is hardworking and interested in patient care needs Both In and Out Patient work is required Seeing

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Psychiatrist wanted for opportunity located on the Blue Pacific shore. Live the California lifestyle of beaches, mountains, and theme parks. Ventura County is a short commute to Los Angeles, live

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100925-1359 Psychiatrist - Beautiful WesternNew York NY Excellent opportunity for BE/BC psychiatrist at 186-bed facility with existing behavioral health unit Thriving friendly community of 15,000

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110606-1561 Psychiatry - Near Knoxville, TN TN Seeking BC/BE psychiatrist to join behavioral health center Employed position doing all inpatient Work as member of an interdisciplinary team Call

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Our agency has multiple Psychiatry positions available in Michigan permanent and part-time. Please contact Dianne Hamilton of Medical Resources LLC at 877-297-4084, x106 to discuss the various

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101210-1470 Psychiatrist - Cincinnati, OH OH Seeking fellowship trained "Adult" psychiatrist for 30-bed inpatient psychiatric unit Crisis intervention and individualized, structured treatment are

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Employee performs duties as a practitioner and consultant in Psychiatry with emphasis on problems of all levels of complexity and must come to the position with knowledge and experience (ideally working

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100104-878 Psychiatry - North Dakota ND Adult psychiatrist to join multi-disciplinary psychiatry department Faculty appointment and teaching of psychiatry residents is available Excellent compensation

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110923-1748 Psychiatrist - Minnesota MN Seeking BC/BE psychiatrist to join highly regarded multi-specialty group H1Bs welcome In and out patient service Call: 1:4, usually light Competitive

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110607-1570 Psychiatrist - Louisiana LA Seeking BC/BE general psychiatrist for 200-bed psychiatric and chemical dependency treatment facility Inpatient and some outpatient coverage Staff position

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100104-879 Psychiatrist - Minnesota MN BC/BE Adult Psychiatrist to join its clinic-based practice J1 and H1Bs welcome Excellent compensation and benefit plan Live and work in a beautiful Minnesota

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100808-1278 Psychiatrist - Arkansas AR Seeking BC/BE Psychiatrist for new state of the art behavioral health treatment facility Any sub-specialty is welcome for inpatient services If interested

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100608-1108 Psychiatrist - Kentucky KY BC/BE psychiatrist for private practice opportunity Affiliated with 259 bed facility Competitive compensation with excellent benefits package Community

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111019-1771 Psychiatry - Wisconsin WI Seeking BC/BE Adult psychiatrist to join multi-specialty group affiliated with highly regarded health system Ideal candidate will have interest in inpatient

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We have an excellent opportunity available for a Psychiatrist in the Greater Oklahoma City area of OK. This is a permanent opportunity with great compensation and incentives.

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100910-1343 Psychiatry - Nebraska NE Seeking BC/BE psychiatrist to cover general adult cases J1s/H1Bs welcome Includes option to pursue an area of interest Hospital employed position Practice

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A large prestigious facility in the Greater Fayetteville, NC area has an excellent opportunity for a BC/BE Psychiatrist. Board Certified is preferred but Board Eligible will be accepted.

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101203-1454 Psychiatry - Georgia GA Seeking BC/BE psychiatrist for employed inpatient only position Physician will be attending for outpatient programs plus fill role as "telehealth consultant"

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Location New Zealand, North Island Population 35,000 - 60,000 Provider Qualifications Specialist/Consultant Benefits CME Paid Vacation Relocation Package Location Highlights Near

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Board Certified/Board Eligible General Adult Psychiatrist opportunities available at several locations. Positions are all salaried employment with benefits. No call. ALL Inpatient. Don't worry about

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Employee works under the supervision of the Commander of the Health Clinic. Employee works with full professional responsibilities for his/her actions and advice. Carries out duties in accordance with

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Permanent psychiatrist needed for inpatient position in Utah. Active, unrestricted Utah license required. Inpatient duties working with Adult and Geriatric patient population and sharing in on-call rotation

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Our client in the Greater Alleghany, NY area is looking for a BC/BE Permanent Psychiatrist to join their team. BC/BE Monday - Friday work week with 1:3 call rotation Hospital Employed

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Our client in the Greater Syracuse, NY area is seeking a BC/BE Psychiatrist to join their hospital based facility. Board Certified is preferred but Board Eligible will be accepted.

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Our client in the Greater Syracuse, NY area is seeking a BC/BE Psychiatrist to join their hospital based facility. Board Certified is preferred but Board Eligible will be accepted.

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Client needs vacation coverage for Psychiatrist in MI! Client needs BC Psych in Child Psychiatry to provide coverage 4/11-4/23. Will work in Child and Adolescent inpatient unit. Great support staff!

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A psychiatrist is needed in Missouri for locum tenens coverage starting Oct. 1st and extending for several months. The coverage need calls for work in the outpatient clinic, Monday through Friday from

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Scenic Community in North Carolina is looking for a Psychiatrist to provide coverage for the next 5 to 6 months while they recruit for 2 permanenet providers. The Psychiatrist will work inpatient, seeing

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One of Onyx MD's clients located in North Carolina is looking for a Psychiatrist to cover shifts ASAP until July 2012! If you only have 2 to 3 months of availability client will still be interested in

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Enjoy coastal living in SE Massachusetts. Our clients seeks an immediate full-time, 32-hour-per-week board-certified/eligible psychiatrist to share responsibilities between treating patients in our Partial

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Psychiatry jobs in "West/Central" - PA

We have an outstanding opportunity for you to come join a well-established facility in the West/Central area of PA as a BC/BE Psychiatrist. Board Certified is preferred but Board

Psychiatry jobs in "West/Central" - PA

We have an outstanding opportunity for you to come join a well-established facility in the West/Central area of PA as a BC/BE Psychiatrist. Board Certified is preferred but Board

Psychiatry jobs in "West/Central" - PA

Our client in West/Central PA is currently seeking a BC/BE Psychiatrist for a solo opportunity in a thriving established practice. Board Certified is preferred but Board Eligible will be accepted.

Psychiatry jobs in "Southwestern" - IN

Hi Dr., Join a well-trained group of Psychiatrists and professional support staff in the very charming Southwestern area of Indiana. Opportunity for Chief

Psychiatry jobs in "Boston area" - MA

Staff Psychiatry and Clinical/ Administrative positions with multiple sites in the Boston, MA area - Central city and suburbs. Clinical/Administrative positions may include Service Director and Medical

Psychiatry jobs in "Whitesburg" - KY

Whitesburg ARH Hospital BC/BE Psychiatrist Whitesburg ARH Hospital is seeking a BC/BE Psychiatrist to join its medical staff. Our 90-bed community hospital prides itself with a high tech-high touch

Psychiatry jobs in "Charleston" - WV

We have a fantastic opportunity available for you in the Charleston area of WV for a BC/BE Psychiatrist. Board Certified is preferred but Board Eligible will be accepted. 100% Out-patient

Psychiatry jobs in "PSY 166792" - CA

CALIFORNIA PSYCHIATRY ACADEMIC APPOINTMENT IMMEDIATE NEED FOR A PSYCHIATRIST TRULY MAKE AN IMPACT IN THIS COMMUNITY Nationally recognized Psychiatry Residency program Work

Psychiatry jobs in "Fort Wayne" - IN

A hospital owned multi-specialty group in the Greater Fort Wayne area of Indiana is seeking a BC/BE Psychiatrist with experience working with the adult and geriatric population.

Psychiatry jobs in "Esat texas" - TX

We have openings for permanent placement in locations such as San Antonio, Beaumont area and northern Louisiana! If interested in discussing and being introduced for these opportunities contact

Psychiatry jobs in "Cape area" - MA

I have an immediate opportunity available for a Psychiatrist in the Cape area of MA. This is a permanent position that offers great compensation and great incentives!!!! BC/BE Client

Psychiatry jobs in "PSY 47648" - AZ

Psychiatry Beautiful University Town Arizona Without the Heat! Hospital employed position offering an extremely competitive salary plus bonuses Join an extremely

Psychiatry jobs in "Knoxville" - TN

Adolescent Psychiatrist Needed in Knoxville, TN for an ongoing assignment or permanent position Our client in Knoxville, TN is seeking a BE/BC Psychiatrist for a full or part time locum assignment and/or

Psychiatry jobs in "Baltimore" - MD

I am working with a client in Maryland that has a permanent Psychiatry opportunity. This location is ideal, if you are interested, please email or call Amie Bigelow at 877-706-4949 ext. 12 or amie.bigelow@medsearchint.com.

Psychiatry jobs in "Southwest" - MI

Inpatient and outpatient opportunities. Adult and child positions available. Responsible for providing assessment, counseling, treatment and giving referrals and advocacy services for patients. Other

Psychiatry jobs in "SouthEast" - FL

Cushy job for a psychiatrist. Out patient only. Call is one week out of every 4. Since it is out patient, you would get very few call. No inpatient of Hospital call. Will take psych of all ages.

Psychiatry jobs in "Gillette" - WY

Practice in Wyoming Psychiatry Practice opportunity, good case mix, great colleagues and large referral base, Attractive salary Sign-on and incentivizes CME and several other benefits Gillette,

Psychiatry jobs in "Sandusky" - OH

Firelands Regional Medical Center invites you to become a member of one of the most progressive healthcare teams in North Central Ohio. The medical Center is seeking a BE/BC psychiatrist to join its

Psychiatry jobs in "Northern" - NJ

We have an outstanding opportunity in the Northern area of NJ for a Permanent BC/BE Psychiatrist. Board Certified is preferred but Board Eligible will be accepted. Schedule is flexible

Psychiatry jobs in "Northern" - NJ

We have an outstanding opportunity in the Northern area of NJ for a Permanent BC/BE Psychiatrist. Board Certified is preferred but Board Eligible will be accepted. Schedule is flexible

Psychiatry jobs in "Multiple" - MI

Facility in MI is recruiting for multiple Psychiatrists throughout the state. Adult and Child positions available. Both inpatient and outpatient opportunities. Call or email for details!

Psychiatry jobs in "Central" - AZ

This facility is in a thriving and pleasant community just north of Phoenix. This position evaluates and treats children, adolescents and adult psychiatric outpatients; evaluates and treats

Psychiatry jobs in "Central" - AK

Residential Treatment and Inpatient for child/adolescent patient populations. Programs have grown which is reason for recruitment. Call is reasonable as is daily work schedule and caseload. Medical staff

Psychiatry jobs in "Hazard" - KY

Hazard ARH Hospital BC/BE Psychiatrist Hazard ARH Regional Medical Center is seeking a BC/BE Psychiatrist to join its medical staff. Our 308-bed regional medical center prides itself with a high tech-high

Psychiatry jobs in "Dallas" - TX

Excellent Opportunity for a Psychiatrist in Exciting Dallas, Texas! If you are looking for a great position with no call, no nights and no weekends then this is the position

Psychiatry jobs in "Minot" - ND

A very prestigous group in Minot, ND is seeking an Adult and/or Child Adolescent Psychiatrist to join their team. Easy aiport access! Excellent compensation! Flexible call! Please reference

Psychiatry jobs in "Sandy" - UT

GENERAL PSYCHIATRIST NEEDED to provide provide general psychiatric services to children and adults, including psychiatric evaluations (both routine and emergent), as well as medications, medication

Psychiatry jobs in "West" - NC

BC/BE Psychiatrist needed to join a solo doc. Both will round on inpatients, participate in treatment team, and see patients in the private office. Call will be 1:4. Week day call is handled by phone

Psychiatry jobs in "East" - GA

BC/BE Outpatient Psychiatrist (Child & Adolescent OR Adult) needed for FT position. This will be an outpatient position in a brand new office space. Shared call will be 1:4 or less. Salary plus bonus

Psychiatry jobs in "East" - GA

BC/BE Psychiatrist opportunity. This will be a 100% inpatient clinical position. The age range for the inpatient population is 6 through Geriatric. The opportunity will have standard 9-5 hours and will

Psychiatry jobs in "" - NZ

Location New Zealand, South Island Population 65,000 - 100,000 Provider Qualifications Specialist/Consultant Location Highlights Near Coast

Psychiatry jobs in "" - TX

Texas PsychiatryBase Salary up to $280,000 Here, we honor individualism as well as teamwork. We take our time with our patients. We strive to arm ourselves with the latest techniques in an effort

Psychiatry jobs in "" - WA

We are currently recruiting a Psychiatrist for our hospital.This an inpatient psychiatric unit, which provides acute voluntary and involuntary treatment of psychiatric disorders - with the exception