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Objective: Published reports indicate that African Americans are underrepresented among patients treated with ECT. The reason for this disparity in practice has not been determined. This study addressed this question by using existing data on a large series of patients treated with ECT at a single academic medical center. Method: The hospital's administrative databases were used to select Caucasian and African American patients with a diagnosis of major affective disorder treated over the period from November 1993 to March 2002. Independent variables were age, sex, treatment unit, readmission within 30 days, type of insurance, and geographic zone of residence. The dependent variable was likelihood of being treated with ECF, computed for each race group. Results: Caucasians were more likely than African Americans to be treated with ECT (odds ratio=4.71; 95% confidence interval [Cl]=3.77-5.90). None of the variables examined provided an explanation for this disparity. When all of the variables were controlled simultaneously, the likelihood of being treated with ECT remained significantly higher for Caucasians than for African Americans (odds ratio=2.48; 95% Cl=1.89-3.25). Conclusions: The racial disparity in the use of ECT cannot be explained on the basis of the variables studied. It is not an artifact of the age of the patient population, nor can it be explained on the basis of insurance coverage, the social class of the patients, or their illnesses' being more treatment resistant. The authors propose several other hypotheses, including explanations relating to clinical presentation, differential response to other treatments, differences in patients' willingness to consent, and physicians' behavior, that could be explored by using other methods.

Objective: Psychiatric literature over the past 100 years suggests that Jews are at higher risk for affective disorders than members of other religious groups. To examine these claims, the authors analyzed data from the National Institute of Mental Health Epidemiologic Catchment Area (ECA) study. In addition, the relationships among gender, alcoholism, and major depression were investigated. Method: The period prevalence and lifetime rates of DSM-III major depression among Jews, Catholics, Protestants, individuals in other religious groups, and individuals with no religious affiliation were examined in the Los Angeles and New Haven, Conn., ECA data. Logistic regression with covariates for site, gender, marital status, and socioeconomic status was used to estimate odds ratios and 95% confidence intervals. The calculated rates, based on the combined data from ECA study waves 1 and 2 for the white population, were weighted according to the 1980 U.S. population census. Female-to-male rate ratios and rates of alcohol abuse/dependence were also obtained. Results: While no differences were found among females, Jewish males had significantly higher rates of major depression than Catholics, Protestants, and all non-Jews combined. Jews had a 1:1 female-to-male ratio for major depression, in contrast to the other religious groups, which approached the universal 2:1 ratio. Rates of alcohol abuse/dependence were inversely related to rates of major depression. Conclusions: The results support only in part the earlier reports that Jews have higher rates of major depression. The equal gender distribution of major depression among Jews may be associated with the lower rate of alcoholism among Jewish males.

Objective: This study tested the impression that there have been significant shifts in the relative diagnostic frequencies of schizophrenia and major affective disorders. Method: Data on discharge diagnoses from 1972 to 1988 were gathered from six North American psychiatric teaching hospitals (data from one extended through 1991), and rates for schizophrenia and major mood disorders were evaluated. Results: Total annual discharges increased by 6.6% during the study period. Large reciprocal shifts in the frequencies of diagnoses of schizophrenia and major affective disorders were found; schizoaffective disorder was a minor diagnosis. Beginning in the early 1970s, a gradual increase in the frequency of diagnoses of major affective disorders at all sites was accompanied by a corresponding decrease in diagnoses of schizophrenia at five of the six centers. Schizophrenia diagnoses decreased from a peak of 27% in 1976 to 9% in 1989 (a threefold decrease), and diagnoses of major affective disorders rose from a low of 10% in 1972 to 44% in 1990 (a fourfold increase). Conclusions: Several forces may have influenced these changes. 1) DSM-III narrowed the definition of schizophrenia and broadened the category of major affective disorders. 2) Treatment-oriented diagnostic bias associated with the availability of lithium and other mood-altering agents may have encouraged consideration of affective disorders. 3) Economic and social forces, including better third-party reimbursement rates, may have favored affective diagnoses. 4) True increases in the incidence of affective disorders may have occurred. 5) Although a real decrease in new cases of schizophrenia may have occurred, this effect was probably minor and dominated by a larger shift of such diagnoses to affective categories.

Objective: This study was designed to ascertain the degree and specificity of cognitive impairments in patients with schizophrenia and patients with affective disorders. Method: Cognitive function was assessed with a neuropsychological test battery in consecutively admitted patients with schizophrenia (N=57), unipolar depression (N=29), and bipolar disorder (N=16). Results: The performance of the schizophrenic group was significantly below that of the groups with affective disorders on measures of attention and psychomotor speed, verbal and visual memory, and problem solving and abstraction. IQ was lower in the schizophrenic group and appeared to have deteriorated from a normal premorbid level that was not different from that of the affective disorder groups, as determined by the Wide Range Achievement Test - Revised reading test, a putative measure of premorbid intelligence. When IQ was controlled, differences between the groups in problem solving and visual memory remained. Psychiatric symptoms had a larger impact on test performance in the affective disorder groups than in the schizophrenic group. Conclusions: These results suggest that patients with schizophrenia perform systematically worse on cognitive measures than patients with affective disorders, which is consistent with their generally poorer outcome. The results also indicate that schizophrenia and affective disorders are qualitatively distinguishable in neuropsychological terms, given differences in apparent intellectual deterioration, profiles of cognitive impairment, and associations between cognitive performance and psychopathology.

Objective: This analysis aimed to quantify the long-term stability of distinctions between nonbipolar, bipolar II, and bipolar I affective disorders and to determine the predictors of shifts in patients' diagnoses among these categories. Method: Probands entered the study as they sought treatment for manic, major depressive, or schizoaffective disorder diagnosed according to the Research Diagnostic Criteria. After thorough baseline evaluations, 605 patients with nonbipolar major depressive disorder or schizoaffective disorder, depressed type; 96 with bipolar II disorder; and 231 with bipolar I disorder or schizoaffective disorder, manic type, began the follow-up study. Direct interviews took place at 6-month intervals for the first 5 years and annually thereafter. Results: Only 20 (5.2%) of the 381 initially nonbipolar probands who completed 10 years of follow-up developed mania during that time, and only 19 (5.0%) developed hypomania. A slightly higher proportion of the 67 who began with bipolar II disorder developed mania during the 10 years. Although 101 (66.4%) of the 152 bipolar I or schizoaffective manic probands developed subsequent manic episodes, only 11 (7.2%) developed hypomanic episodes and no mania. Young age at intake and at onset and chronicity of the index episode predicted shifts from nonbipolar to bipolar II disorder. Psychosis and a family history of mania predicted shifts from nonbipolar to bipolar I disorder. Conclusions: The high stability of baseline distinctions between nonbipolar, bipolar II, and bipolar I disorders, in combination with previously described family study data, strongly supports the separation of these disorders for both clinical and research purposes.

Researchers have increasing emphasized the distinction between positive and negative symptoms of schizophrenia. Positive symptoms include delusions, hallucinations, and certain types of thought disorder; flat affect and other types of thought disorder are considered negative symptoms. These groups of symptoms are hypothesized to represent different underlying processes in the disease. In the present study, positive and negative symptoms and social competence were measured in 44 children at risk for schizophrenia, 38 children at risk for affective disorders (e.g., depression), and 62 matched normal children. The children were considered at-risk for a particular disorder, if they had a parent with that disorder. The study was longitudinal in design; at the first assessment, children were an average of 9 years old; at the second, they were an average of 12.3 years old; and at the third evaluation, they were an average of 15.4 years old; representing childhood, early adolescence, and adolescence, respectively. In childhood, there were no significant group differences on measures of social competence, negative symptoms, or positive symptoms as rated by standardized scales. By early adolescence, however, children at risk for schizophrenia began to show a deficit in social competence compared with the normal control children and the children at risk for affective disorders. They also had more positive thought disorders than children at risk for affective disorder, but they did not differ from normal children in this regard. There were no differences among the groups on negative symptoms. In adolescence, children at risk for schizophrenia maintained a relatively poor level of social competence compared with the other groups and had greater positive and negative symptoms. It is concluded that children at risk for schizophrenia are more likely than others to have social deficits in early adolescence and adolescence, and these children also have greater positive and negative symptoms in adolescence. (Consumer Summary produced by Reliance Medical Information, Inc.)

Objective: The purpose of this study was to develop a clinician-based cognitive, psychoeducational, preventive intervention for families with parental affective disorder that would be suitable to widespread use, test its feasibility and safety, and define the areas affected by the intervention. The intervention was designed to increase understanding of parental illness and resilience in the children. Method: The authors studied the first seven families (14 parents) to receive the intervention. Enrollment criteria included affective disorder during the preceding year in at least one parent, presence of at least one child between the ages of 8 and 14 years who was not psychiatrically ill at the time of participation, and willingness to participate in the research study. The intervention consisted of parent, child, and family sessions. Assessment included semistructured interviews with parents about affective disorders, standard ratings of marital satisfaction and therapeutic alliance, and a recently developed semistructured interview to assess response to the intervention. Results: Overall satisfaction with the intervention was rated moderate to high by parents. No harm was reported. Ten of 14 parent subjects reported five or more behavior and attitude changes that they attributed to the intervention. The most frequent behavior and attitudinal changes reported were increased discussion of the illness and related issues and increased understanding of information about affective illness. Conclusions: The authors conclude that the intervention is safe and feasible in families with parental affective disorder.

Prodromal symptoms, or the signs and symptoms that precede a disorder and that are distinctly different from those found during the acute phase of the disorder, are important in medicine because early detection of illness is often crucial to favorable treatment and outcome. But in psychiatry, research on prodromal symptoms has been rare, with the exception of studies regarding schizophrenia. The current article surveys the literature with regard to the prodromal symptoms of affective disorders, such as depression, mania, and anxiety. Twenty-four studies were found that specifically addressed the issue of prodromal symptoms, and they were in agreement that the prodromal phase, at least for mania, depression, and panic attacks, may precede the full-blown acute phase of the illness by weeks and sometimes even months. For mania, the symptoms include headaches, weariness, lack of pleasure, irritability, and sleeplessness. The prodromal phase of depression varies. In sudden-onset depression there appear to be few prodromal symptoms. Gradual-onset depression is related to ongoing stress. Neurotic-onset depression is often preceded by anxiety disorders, and fluctuating-onset depression is characterized by symptoms that fluctuate in intensity before full-blown depression sets in. Symptoms during the prodromal phase of panic disorders have not been agreed upon. Some cite avoidance behavior as a sign, while others say that avoidance is caused by the panic disorder itself. If prodromal symptoms can be more clearly identified, treatment for these disorders could be initiated sooner and might be more effective. It is recommended that attention to prodromal symptoms compliment current standards of clinical assessment, namely the identification of symptoms during the acute phases of psychiatric disorders. Studies that have been completed on prodromal symptoms need to be updated as well, as most were carried out in the 1960s. (Consumer Summary produced by Reliance Medical Information, Inc.)

Objective: Tryptophan hydroxylase is the rate-limiting enzyme in the biosynthesis of serotonin. The authors examined whether polymorphisms A218C and A779C in intron 7 of the tryptophan hydroxylase gene are associated with a risk for affective disorders or suicidal behavior. Method: Subjects were 141 patients with bipolar disorder and 73 patients with unipolar affective disorder, 46 of whom had a history of attempted suicide, and 208 healthy volunteers. All subjects were unrelated to each other, and all were Japanese. Genotyping was performed by polymerase chain reaction amplification followed by digestion by a restriction enzyme and single-strand conformational polymorphism analysis. Results: There was no significant genotypic or allelic association of the A218C polymorphism with bipolar disorder, unipolar depression, or history of attempted suicide. In nearly 100% of the subjects, genotypes for the A779C were identical to those for the A218C. Conclusions: The authors conclude that the examined polymorphisms are unlikely to have major relevance to the pathogenesis of affective disorders or suicidal behavior.

Seasonal depression shares certain common symptoms with nonseasonal depression; however, the two disorders have never been examined in a single study, to the authors' knowledge. The goal of this research was to examine the potential similarities in cognitive impairments in seasonal affective disorder and major depressive disorder in college students in the Midwest. Identification of affective disorders was based on participants' self-reported behavior and affect on the Beck Depression Inventory and the Seasonal Pattern Assessment Questionnaire. A group of 93 participants was assessed for major depressive disorder and seasonal affective disorder in late autumn and completed the Cognitive Failures Questionnaire for reported diffi culties in everyday activities that correspond to problems with perception, attention, and memory retrieval. The results indicated that seasonal affective disorder was highly prevalent (28.0%), substantially more so than major depressive disorder (8.6%). Similar to previous research on major depressive disorder, gender differences were also evident among participants with seasonal affective disorder, with more women qualifying than men. Both affective disorders were associated with higher reports of cognitive failures in comparison to participants with no depressive symptoms. These results reveal that individuals with seasonal affective disorder showed cognitive impairments similar to those with nonseasonal depression.

The authors used the Wisconsin Card Sorting Test to study 50 hospitalized psychiatric patients: 28 with schizophrenia, 17 with affective disorders, and five with schizoaffective disorder. The schizophrenic patients performed significantly more poorly than the patients with affective disorders. Both groups of patients improved when given additional instructions. The schizophrenic patients maintained their improvement when retested approximately 6 weeks later. The results suggest that factors other than frontal cortex dysfunction are involved in schizophrenic patients' performance on the Wisconsin Card Sorting Test.

Objective: The authors' goal was to determine if the actual treatment of schizoaffective and bipolar affective disorders has changed in light of recent clinical drug trials that have suggested that valproate and carbamazepine may be equivalent in efficacy to lithium. Method: Medication utilization rates for each 6-month period from July 1, 1989, to June 30, 1994, were compiled from the clinical database of the Palo Alto Veterans Affairs Medical Center. Results: The use of valproate and valproate plus lithium was negligible in 1989. By 1994, these medication regimens accounted for 25% of the standard antimanic treatments used for bipolar affective disorder and 38% of the treatments used for schizoaffective disorder. Regimens of carbamazepine and carbamazepine plus lithium dropped from 24% of antimanic treatments in 1989 to 18% in 1994. From 1989 to 1994, there was a decline in the rate of lithium monotherapy for treatment of bipolar affective disorder (from 84% to 43%) and schizoaffective disorder (from 100% to 53%). Conclusions: In the past 5 years, valproate monotherapy has increased as a percentage of total antimanic pharmacotherapies, while lithium mono-therapy has declined.

Objective: This study ascertained the incidence of complications during pregnancy, labor, and delivery and the neonatal characteristics of infants born to women with schizophrenia, bipolar disorder, or major depression in a population-based cohort. Method: Based on records linkage across a psychiatric case register and prospectively recorded obstetric data, the study comprised women with schizophrenia or major affective disorders who had given birth to 3,174 children during 1980-1992 in Western Australia. A comparison sample of 3,129 births to women without a psychiatric diagnosis was randomly selected from women giving birth during 1980-1992. Complications were scored with the McNeil-Sjostrom Scale. Odds ratios were calculated for specific reproductive events. Results: Both schizophrenic and affective disorder patients had increased risks of pregnancy, birth, and neonatal complications, including placental abnormalities, antepartum hemorrhages, and fetal distress. Women with schizophrenia were significantly more likely to have placental abruption, to give birth to infants in the lowest weight/growth population decile, and to have children with cardiovascular congenital anomalies. Neonatal complications were significantly more likely to occur in winter; low birth weight peaked in spring. Complications other than low birth weight and congenital anomalies were higher in pregnancies after psychiatric illness than in pregnancies preceding the diagnosis. Conclusions: While genetic liability and gene-environment interactions may account for some outcomes, maternal risk factors and biological and behavioral concomitants of severe mental illness appear to be major determinants of increases in reproductive pathology in this cohort. Risk reduction in these vulnerable groups may be achievable through antenatal and postnatal interventions.

Objective: Three linkage studies of bipolar disorder have implicated chromosome 12q24.3, with significant Iod scores of over 3.00. Several other linkage studies have found Iod scores between 2.00 and 3.00. In order to identify which gene on this chromosome is responsible, the authors carried out tests of allelic association with bipolar disorder in order to fine map an affective disorder susceptibility gene. Method: DNA samples from 681 bipolar disorder patients and 570 comparison subjects from Denmark and the United Kingdom were genotyped with markers close to the region at which the authors had found maximum linkage in previous studies. Results: Single marker allelic association was found with four markers in the Danish cohort. Seven markers in exactly the same region were then found to show significant allelic association in the U.K. cohort. Tests of haplotypic association were also significant, confirming the single marker allelic associations. Conclusions: These positive fine mapping results validate earlier linkage studies and implicate a 278-kilobase region of chromosome 12 that contributes to the etiology of bipolar disorder. Several brain transcripts are transcribed from sequences in the region. The main candidate gene has no known function but is found in human brain cDNA and is homologous to a Macaque brain cDNA. Sequencing of expressed sequences and control regions in the area should identify etiological base pair changes that increase susceptibility to bipolar disorder.

Schizoaffective disorder is characterized by symptoms of both schizophrenia and affective illness, which include mood disorders such as depression. Whether it is a form of schizophrenia or affective illness, part of a continuum of both, or a completely separate condition, remains a topic of debate. The approaches to solving this dilemma take a variety of directions, one of which is to compare the outcome of those with schizoaffective disorder, schizophrenia, and affective disorder. A group of 101 psychiatric patients were assessed, which was composed of 41 schizoaffective patients, 20 schizophrenics, 20 patients with bipolar illness, and 20 patients with major depressive illness. Functioning and overall adjustment were assessed for all patients at initial intake, two years after hospitalization, and four-to-five years after discharge. Overall, schizoaffective, schizophrenic, and bipolar patients functioned more poorly than depressives after discharge from the hospital. These results did not change over time; at two-year follow-up, depressed patients had the highest level of functioning, followed by those with bipolar disorder, subjects with schizoaffective disorder, and schizophrenics; at the second follow-up, this pattern remained the same. Overall, the outcome of schizoaffective patients was similar to both schizophrenics and those with affective disorders, making it likely that schizoaffective disorder is not just a variant of affective disorder. (Consumer Summary produced by Reliance Medical Information, Inc.)

Objective: The current research was designed to investigate the relationship between affective disruption and psychosis in unipolar major depressive disorder and to evaluate whether some depressed patients are particularly vulnerable to subsequent psychosis. Method: A group of 31 psychotic and 63 nonpsychotic inpatients with unipolar depression were assessed during hospitalization and then prospectively assessed for depressive and psychotic symptoms 2.4 years after hospital discharge. Results: The psychotic depressed inpatients had significantly higher rates of psychosis during the posthospital period, 2.4 years later, than the originally nonpsychotic depressed inpatients. However, they did not have higher rates of depressive syndromes during the posthospital period. Psychosis during the posthospital period was significantly related to recurrent or persistent affective disruption. The posthospital depressive syndromes of the initially psychotic depressed inpatients tended to be slightly more severe than those of the initially nonpsychotic depressed inpatients. Despite this, psychosis during the inpatient period was more predictive of posthospital psychosis than the severity of the posthospital depressive syndrome. Conclusions: The interaction of the following two factors was proposed to be central to psychotic depression: 1) a vulnerability to psychosis, and 2) concurrent affective disruption.

Cyclothymia refers to the phenomenon of cyclic changes in mood, such as occur with manic depressive illness at the extreme ends of the mood spectrum. To assess relationships between cyclothymic mood swings and psychosocial adjustment, 38 depressed (unipolar), 27 manic depressive (bipolar) and 27 other psychiatric patients were studied four years after hospital discharge; a control group of 153 normal subjects was also included in the study. The patients had much greater mood swings than the control group, but among the patients, there were no significant differences. In terms of the ability to function and cope after hospitalization, the cyclothymic patients were much less adept than the other psychiatric patients. The findings suggest either that cyclothymia itself interferes with psychosocial function, or else cyclothymic mood swings result from a broader underlying factor that increases the probability of poor social functioning. The authors suggest the latter hypothesis is more likely, and indicate that minor mood swings in patients who have a hard time adjusting after psychiatric hospitalization may in fact be reflecting a persistent vulnerability to psychopathology.