at Johns Hopkins Bloomberg School of Public Health recently examined the
prevalence of sleep problems and their association with the use of inpatient
and emergency department services by Medicaid recipients with serious mental
illness. Their sample consisted of 1,560 psychiatric patients with Medicaid
coverage who were identified in a 10-state random survey of psychiatrists.
Sleep problems were assessed by clinicians' clinical judgment, rated on a scale
as none, mild, moderate, or severe. The researchers hypothesized that patients
with sleep problems would be more likely to have psychiatric hospitalizations
and psychiatric emergency department visits than those without sleep problems
and that use of these services would be more prevalent among patients with more
severe sleep problems.
They found that about 80 percent of patients in the sample had
some sleep problems, according to ratings by their psychiatrists. Approximately
half of patients were described as having either moderate or severe problems,
suggesting that sleep problems were highly prevalent in this population.
"More careful monitoring and
management of sleep problems in this patient population could address a common
clinical need and might help to reduce costly service use," said the
researchers. They called for the use of standardized measures in routine
practice settings, such as the Pittsburgh Sleep Quality Index and the Insomnia
Severity Index, to improve clinicians' ability to screen for and diagnose sleep
disturbances and monitor treatment responses.
Kaufmann C, Spira A, Rae D, et al. Sleep Problems,
Psychiatric Hospitalization, and Emergency Department Use Among Psychiatric
Patients with Medicaid. Psychiatr Serv. 2011. 62(9):
1101-1105. An abstract is posted at
The combination of prolonged
exposure, a cognitive-behavioral therapy (CBT), and paroxetine
was more effective in the treatment of posttraumatic stress disorder (PTSD)
related to the World Trade Center attack than prolonged exposure plus placebo.
Researchers at Columbia University Medical Center studied adults
who were referred by clinicians, responded to advertisements, or responded to
direct mail to individuals who had either sought help from the Mental Health
Association of New York City for difficulties related to the World Trade Center
attacks or who participated in the World Trade Center Health Registry and
screened positive for PTSD (score of 50 or more on the PTSD Checklist).
Thirty-seven survivors of the WTC attacks with PTSD were randomly
assigned to 10 weeks of treatment with prolonged exposure (10 sessions) plus paroxetine (n=19) or prolonged exposure plus placebo
(n=18). PTSD severity was assessed using the Clinician-Administered PTSD Scale
and the 7-point Clinical Global Impressions of Change scale.
Patients treated with
prolonged exposure plus paroxetine showed
significantly greater improvement in PTSD symptoms and remission status.
Response rate and quality of life were also significantly more improved with
"Combined treatment medication
and prolonged exposure therapy deserves further study in larger samples with
diverse forms of PTSD and over longer follow-up periods," concluded the
The study was supported by a
National Institute of Mental Health grant to coauthors Randall Marshall, M.D.,
and Franklin Schneier, M.D. Schneir has received research funding from Forest Laboratories, and Marshall is currently employed by SunovionPharmaceuticals. Glaxo-SmithKline provide the paroxetine and matching
placebo tabled used in this study.
Schneier F, Neria Y, Pavlicova M, et al.
Combined Prolonged Exposure Therapy and Paroxetine
for PTSD Related to the World Trade Center Attack: A Randomized Controlled
Trial. Am J Psychiatry. 2011. Sep 9 [Epub ahead of print]. An abstract is posted at
Researchers at the University of
Utah have concluded that children with migraine with aura have a significantly
higher prevalence of patent foramen ovale (PFO)
compared with those without aura or with the general population. They studied
109 children and adolescents aged 6 to 18 who were diagnosed with migraine
headache (38 with aura and 71 without) by pediatric neurologists from February
2008 to September 2009. The children were evaluated for PFO and right-to-left
shunting with color-flow Doppler scanning, saline solution contrast transthoracic echocardiography, and contrast transcranial Doppler scanning
The overall PFO prevalence in
the study cohort was 35 percent; in the general population it is 25 percent.
PFO prevalence in subjects with aura was significantly greater (50 percent),
but similar to the general population in those children without aura.Atrial shunt size was not associated with the presence or
absence of aura.
The researchers believe their data suggest that PFO may
contribute to the pathogenesis of migraine with aura in children and may have
implications for clinical decision making.
McCandless R, Arrington C,
Nielsen D, et al. Patent Foramen Ovale in Children With Migraine Headaches. J Pediatr. 2011. 159(2):243-247. An abstract is posted at <www.ncbi.nlm.nih.gov/pubmed/21450305>
Adverse effects on work
performance are consistently ranked among the most prominent components of the
societal burden of insomnia. Estimates of annual insomnia-related workplace
costs due to excess sickness absence, reduced work productivity, and workplace
accidents and injuries in the U.S. civilian workforce range between $15 billion
and $92 billion.
With the America Insomnia Survey, researchers sought to estimate
the prevalence and associations of broadly defined insomnia (without comorbid conditions) with work performance. A national
sample of 7,428 employed health-plan subscribers over age 18 responded to a
telephone survey. Broadly defined insomnia was assessed with the Brief Insomnia
Questionnaire. Work absenteeism and presenteeism (low
on-the-job work performance defined in the metric of lost workday equivalents)
were assessed with the WHO Health and Work Performance Questionnaire.
The estimated prevalence of insomnia was 23.2 percent. Insomnia
was significantly associated with lost work performance due to presenteeism but not absenteeism, with an annualized
individual-level association of insomnia with presenteeism
equivalent to 11.3 days of lost work performance. The authors called for
effectiveness trials to obtain precise estimates of return-on-investment of
programs that help employees manage insomnia.
Kessler R, Berglund P, Coulouvrat
C et al. Insomnia and the Performance of U.S.
Workers: Results From the America Insomnia Survey Sleep.
2011. 34(9):1161-1171. An abstract is posted at
Women are twice as likely
as men to develop major depressive disorder (MDD) and are more prone to
recurring episodes. Researchers at the University of
Pittsburgh School of Medicine tested the hypothesis that the illness may
associate with robust molecular changes in women
and investigated large-scale gene expression in the postmortem brains of 21
women with MDD and 21 similar women without a history of depression.
Their search focused on the lateral/basolateralbasomediancomplex of the amygdala as a neural hub of mood regulation
affected in MDD.
Among the most robust findings
were downregulated transcripts for genes coding for γ-aminobutyric acid
(GABA) interneuron-related peptides, including somatostatin,
tachykinin, neuropeptide Y,
and cortistatin, in a pattern reminiscent of that
previously reported in mice with low brain-derived neurotrophic
BDNF itself was significantly downregulated
at the RNA and protein levels in subjects with MDD. Investigating putative
mechanisms, the researchers showed that this core MDD-related gene profile is
repeated by complementary patterns in mice with constitutive or
activity-dependent decreases in BDNF function. They concluded that these
findings provide both direct and indirect evidence for reduced BDNF function in
the amygdala of femalesubjects with MDD.
"Our findings give us a better
understanding of the biology of this common and often debilitating psychiatric
illness," said senior author Etienne Sibille, Ph.D.,
an associate professor of psychiatry at the University of
Pittsburgh School of Medicine.
Guilloux JP, Douillard-Guilloux
G, Kota R, et al. Molecular Evidence for BDNF- and
GABA-Related Dysfunctions in the Amygdala of Female
Subjects With Major Depression. Mol Psychiatry. 2011 Sep 13 [Epub ahead of print]. An abstract is posted at
People with type 2 diabetes are at risk of cognitive
impairment and brain atrophy. Researchers at the National Institute on Aging
compared the effects on cognitive function and
brain volume of glycemic control. Their findings did not support the use of
intensive therapy to reduce the adverse effects of diabetes on the brain.
The Memory in Diabetes (MIND)
study was conducted at 52 clinical sites in North America as part of Action to
Control Cardiovascular Risk in Diabetes (ACCORD), a clinical trial supported by
the National Institutes of Health that evaluated the effects of intensively
targeting blood sugar control among adults with established diabetes, high
blood sugar levels, and pre-existing heart disease or at least two
cardiovascular disease risk factors in addition to diabetes. In the MIND study,
hemoglobin A1C levels, a standard measure of average blood sugar levels over
the preceding two to three months, were used to monitor participants' blood
sugar. A total of 2,977 participants aged 55 to 80 with type 2 diabetes, high
A1C levels, and a high risk of cardiovascular events were randomly assigned to
receive either intensive glycemic control or standard
glycemic control. The intensive strategy group
targeted an A1C blood sugar level of less than 6.0 percent, similar to that
found in adults without diabetes. The
standard strategy group aimed to lower blood sugar levels to an A1C of 7.0 to
7.9 percent, similar to what is achieved, on average, by individuals treated
for type 2 diabetes in the United States.
Cognitive primary outcome was assessed at baseline and at 20 and
40 months using the Digit Symbol Substitution Test (DSST) score. Total brain
volume, the primary brain structure outcome, was assessed with MRI at baseline
and 40 months in a subset of participants.
In February 2008, raised mortality risk (19 percent excess
mortality at five years) led to the end of the intensive
treatment and transition of those participants to standard treatment. There was
no significant treatment difference in mean 40-month DSST score. The intensive-treatment group had a greater mean total brain
volume than the standard-treatment group.
Although significant differences in total brain volume favored
the intensive treatment, cognitive outcomes were
not different. "Combined with the nonsignifican effects on other ACCORD outcomes, and increased
mortality in participants in the intensive
treatment group, our findings do not support the use of intensive
therapy to reduce the adverse effects of diabetes
on the brain in patients with similar
characteristics to those of our participants," concluded the researchers.
Launer L, Miller M, Williamson J, et al. Effects of Intensive Glucose Lowering on Brain
Structure and Function in People With Type 2 Diabetes (ACCORD MIND): A Randomised Open-Label Substudy. Lancet Neurol. 2011. Sep 27. [Epub
ahead of print]. An abstract is posted at