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Background:Benzodiazepines (BZs) and selective serotonin reuptake inhibitors (SSRIs) are effective in the pharmacologic treatment of panic disorder (PD). However, treatment guidelines favor SSRIs over BZs based on the belief that BZs are associated with more adverse effects than SSRIs. This belief, however, is currently supported only by opinion and anecdotes.Aim:The aim of this review and meta-analysis was to determine if there truly is evidence that BZs cause more adverse effects than SSRIs in acute PD treatment.Methods:We systematically searched Web of Science, PubMed, Cochrane Central Register of Controlled Trials, and clinical trials register databases. Short randomized clinical trials of a minimum of four weeks and a maximum of 12 weeks that studied SSRIs or BZs compared to placebo in acute PD treatment were included in a meta-analysis. The primary outcome was all-cause adverse event rate in participants who received SSRIs, BZs, or placebo.Results:Overall, the meta-analysis showed that SSRIs cause more adverse events than BZs in short-term PD treatment. Specifically, SSRI treatment was a risk factor for diaphoresis, fatigue, nausea, diarrhea, and insomnia, whereas BZ treatment was a risk factor for memory problems, constipation, and dry mouth. Both classes of drugs were associated with somnolence. SSRIs were associated with abnormal ejaculation, while BZs were associated with libido reduction. BZs were protective against tachycardia, diaphoresis, fatigue, and insomnia.Conclusion:Randomized, blinded studies comparing SSRIs and BZs for the short-term treatment of PD should be performed. Clinical guidelines based on incontrovertible evidence are needed.

SummaryWe propose that discussions of benzodiazepines in the current psychiatric literature have become negatively biased and have strayed from the scientific evidence base. We advocate returning to the evidence in discussing benzodiazepines and adhering to clear definitions and conceptual rigour in commentary about them.

Pastoralists depend for their livelihood on raising livestock on natural pasture. Livestock may be selected for meat, milk, wool, traction, carriage, or riding, or a combination. Pastoralists rarely rely solely on their livestock; they may also engage in hunting, fishing, cultivation, commerce, predatory raiding, and extortion. Some pastoral peoples are nomadic and others are sedentary, while yet others are partially mobile. Economically, some pastoralists are subsistence oriented, others are market oriented, and others combining the two. Politically, some pastoralists are independent or quasi-independent tribes, others, largely under the control of states, are peasants, while yet others are citizens engaged in commercial production in a modern state. All pastoralists have to address a common set of issues: gaining and taking possession of livestock, including good breeding stock. Ownership of livestock may consist of individual, group, or distributed rights, managing the livestock through husbandry and herding. Husbandry is selecting animals for breeding and maintenance. Herding is ensuring that the livestock gains access to adequate pasture and water. Pasture access can be gained through territorial ownership and control, purchase, rent, and patronage. Security must be provided for the livestock through active human oversight or restriction by means of fences or other barriers. Manpower is provided by kin relations, exchange of labor, barter, monetary payment, or some combination of these. Prominent pastoral peoples are sheep, goat, and camel herders in the arid band running from North Africa through the Middle East and northwest India, the cattle and small stock herders of Africa south of the Sahara, reindeer herders of the sub-Arctic northern Eurasia, the camelid herders of the Andes, and the ranchers of North and South America.

A tribe is a regional security organization. It ties together a number of local primary face-to-face groups. It is charged with control of territory, defense against outside intruders, and protection of humans, livestock, and productive resources, such as wells and cultivation. Whatever productive activity tribesmen are primarily engaged in, such as pastoralism or cultivation, each male, with the exception of holy men, serves also as a warrior. Tribes are usually defined by a symbolic idiom that asserts a primordial connection among tribesmen. Descent from a common ancestor is an idiom used to define many tribes. Tribal names are often those of the ancestor that all members share. Internal divisions may also be defined by ancestry; a descent idiom allows group divisions at every level of the genealogy. Tribal subgroups are also charged with security and are defined as having “collective responsibility”; that is, the moral norm is that each member is responsible for what other members do and, as a consequence, all members are seen by outsiders as equivalent. There is also a moral norm to aid fellow tribesmen, the obligation stronger for close kin, weaker for more distant kin. Internal tribal relations among subgroups are based on what anthropologists call “balanced opposition” or “complementary opposition.” Each tribal subgroup is “balanced” against other subgroups of the same genealogical order, which in principle, and often in practice, serves as a deterrent against hostile acts. Tribal leadership can take the form of primus inter pares. However, in tribes in contact with states, more formal leadership roles, with at least the trappings of authority and power, can develop. Whatever the role of the tribal leader, he depends upon consent of the tribesmen. In tribal subgroups, political process tends to be highly democratic, and leaders are those who can elicit agreement among the members and then carry out the will of the community. Tribes are social organizations that are not static and do not always maintain form. They respond to environmental opportunities and constraints. If a state nearby is in trouble, with failing leadership and an unruly population, a tribe may mount a campaign to invade and conquer the state, setting itself up as a ruling dynasty. In these cases, tribes lose their tribal characteristics and become a ruling elite. However, if a nearby state gains strength and expands its territorial control, it may overrun and defeat the tribe, encapsulating it, incorporating it, and even assimilating it.

Experienced clinicians are aware that the results from clinical drug trials do not always translate to office practice. This essay suggests that clinicians use their own diagnostic and interviewing skills when treating with medications rather than simply relying on published data or suggested treatment algorithms.

At a fall 2012 conference on the culture of Baluchistan, a Nigerian academic remarked on the offensiveness of the term “tribe,” so considered because of the demeaning way it was used by the British...

The Iranians I know best are the Baluch. During the years 1968–1976 I lived among Baluch for some twenty-seven months. More specifically, I lived primarily among the Dadolzai brasrend, or Dadolzai ...

Nomadism is a technique of population movement used to accomplish a variety of goals. It is used for primary production when the resources to be tapped are distributed thinly over a wide space, or are located in different places in a large region. Commonly nomadism is a technique used in a spatially extensive adaptation. Pastoralists raising domestic animals on natural pasture move from grazed areas to areas with fresh pasture, and from dry areas to those with water. Nomadism follows regular patterns where the resources tapped are reliable and thus predictable. This is common in macro-environmental adaptations to factors such as seasons and altitude. Some pastoralists have mountain adaptations, migrating to high altitudes in summer and low altitudes in winter, an adaptation called transhumance in Europe. Nomadic patterns are more irregular when rainfall patterns, and thus pasturage, are erratic and unpredictable, as is common in desert areas with low rainfall. Among some pastoral peoples, all of the households in the community move together. Among other pastoral peoples, a sector of the populations is nomadic; young and/or mature men migrate with the livestock, while women, children, and elders remain in a stationary home settlement. This is also the pattern in European transhumance. Many pastoral peoples produce primarily for their own subsistence; it is common that they have multi-resource or mixed economies, engaging also in hunting and gathering, horticulture, agriculture, and arboriculture. Economic activities are not limited to primary production; patterns of predation, including raiding and extortion, against other pastoralists, farmers, and traders are widespread. Other pastoral peoples are heavily market-oriented, producing for sale, or have symbiotic relations with hunters or cultivators; it is normal that they are more specialized in their production. But pastoralists can be found at all points on a continuum between subsistence- and market-oriented.

Objectives To investigate the relation between the risk of Alzheimer’s disease and exposure to benzodiazepines started at least five years before, considering both the dose-response relation and prodromes (anxiety, depression, insomnia) possibly linked with treatment. Design Case-control study. Setting The Quebec health insurance program database (RAMQ). Participants 1796 people with a first diagnosis of Alzheimer’s disease and followed up for at least six years before were matched with 7184 controls on sex, age group, and duration of follow-up. Both groups were randomly sampled from older people (age >66) living in the community in 2000-09. Main outcome measure The association between Alzheimer’s disease and benzodiazepine use started at least five years before diagnosis was assessed by using multivariable conditional logistic regression. Ever exposure to benzodiazepines was first considered and then categorised according to the cumulative dose expressed as prescribed daily doses (1-90, 91-180, >180) and the drug elimination half life. Results Benzodiazepine ever use was associated with an increased risk of Alzheimer’s disease (adjusted odds ratio 1.51, 95% confidence interval 1.36 to 1.69; further adjustment on anxiety, depression, and insomnia did not markedly alter this result: 1.43, 1.28 to 1.60). No association was found for a cumulative dose 180 prescribed daily doses) and with the drug half life (1.43 (1.27 to 1.61) for short acting drugs and 1.70 (1.46 to 1.98) for long acting ones). Conclusion Benzodiazepine use is associated with an increased risk of Alzheimer’s disease. The stronger association observed for long term exposures reinforces the suspicion of a possible direct association, even if benzodiazepine use might also be an early marker of a condition associated with an increased risk of dementia. Unwarranted long term use of these drugs should be considered as a public health concern.

Recent electrophysiological studies on the primate amygdala have advanced our understanding of how individual neurons encode information relevant to emotional processes, but it remains unclear how these neurons are functionally and anatomically organized. To address this, we analyzed cross-correlograms of amygdala spike trains recorded during a task in which monkeys learned to associate novel images with rewarding and aversive outcomes. Using this task, we have recently described two populations of amygdala neurons: one that responds more strongly to images predicting reward (positive value-coding), and another that responds more strongly to images predicting an aversive stimulus (negative value-coding). Here, we report that these neural populations are organized into distinct, but anatomically intermingled, appetitive and aversive functional circuits, which are dynamically modulated as animals used the images to predict outcomes. Furthermore, we report that responses to sensory stimuli are prevalent in the lateral amygdala, and are also prevalent in the medial amygdala for sensory stimuli that are emotionally significant. The circuits identified here could potentially mediate valence-specific emotional behaviors thought to involve the amygdala.

Being a tribe member means equality, autonomy, and democracy, but its structural premises are incompatible with modern constitutional democracy and rule-of-law. Philip Carl Salzman spent years in Baluchistan. He describes Baluchi lineage groups: closer kin unite to oppose more distant kin.

The Arab sense of self is influenced by the belief that Arabic is the language of God, and that God chose the Arabs to convey to all of humanity the true religion of Islam. The Arab sense of self is also influenced by the historical facts that the ancestors of today's Arabs conquered much of the known world and dominated it for the better part of a thousand years. However, the last centuries have seen serious setbacks to the Arabs, who have answered with efforts to respond in terms of Arab nationalism, Arab socialism, and Arab modernization. These efforts failed in the arenas of warfare, the economy, and human development. Arabs continue to trail other regions, often by great distances. Over the last decades, the frustration and humiliation in the Arab world have been palpable. What remains for the Arabs is what has been present from the beginning: Islam, which has the virtue of not being refutable in military, economic, or statistical tests. As a result, it is to Islam that Arabs are increasingly turning...

Objective:This study examined the association between a Medicaid prior-authorization policy for second-generation antipsychotic and anticonvulsant agents and medication discontinuation and health service use by patients with bipolar disorder. Methods:A pre-post design with a historical comparison group was used to analyze Maine Medicaid and Medicare claims data. A total of 946 newly treated patients were identified during the eight-month policy (July 2003–February 2004), and a comparison group of 1,014 was identified from the prepolicy period (July 2002–February 2003). Patients were stratified by number of visits to community mental health centers (CMHCs) before medication initiation (proxy for illness severity): CMHC attenders, at least two visits; nonattenders, fewer than two. Changes in rates of medication discontinuation and outpatient, emergency room, and hospital visits were estimated. Results:Compared with nonattenders, at baseline CMHC attenders had substantially higher rates of comorbid mental di...

OBJECTIVE: To address issues concerning potential treatment-emergent "suicidality," a consensus conference was convened March 23-24, 2009. PARTICIPANTS: This gathering of participants from academia, government, and industry brought together experts in suicide prevention, clinical trial design, psychometrics, pharmacoepidemiology, and genetics, as well as research psychiatrists involved in studies in studies of psychiatric disorders associated with elevated suicide risk across the life cycle. The process involved reviews of the relevant literature, and a series of 6 breakout sessions focused on specific questions of interest. EVIDENCE: Each of the participants at the meeting received references relevant to the formal presentations (as well as the slides for the presentations) for their review prior to the meeting. In addition, the assessment instruments of suicidal ideation/behavior were reviewed in relationship to standard measures of validity, reliability, and clinical utility, and these findings were discussed at length in relevant breakout groups, in the final plenary session, and in the preparation of the article. Consensus and dissenting views were noted. CONSENSUS PROCESS: Discussion and questions followed each formal presentation during the plenary sessions. Approximately 6 questions per breakout group were prepared in advance by members of the Steering Committee and each breakout group chair. Consensus in the breakout groups was achieved by nominal group process. Consensus recommendations and any dissent were reviewed for each breakout group at the final plenary session. All plenary sessions were recorded and transcribed by a court stenographer. Following the transcript, with input by each of the authors, the final paper went through 14 drafts. The output of the meeting was organized into this brief report and the accompanying full article from which it is distilled. The full article was developed by the authors with feedback from all participants at the meeting and represents a consensus view. Any areas of disagreement at the conference have been noted in the text. CONCLUSIONS: The term suicidality is not as clinically useful as more specific terminology (ideation, behavior, attempts, and suicide). Most participants applauded the FDA's encouragement of standard definitions and definable expectations for investigators and industry sponsors. Further research of available assessment instruments is needed to verify their utility, reliability, and validity in identifying suicide-associated treatment-emergent adverse effects and/or a signal of efficacy in suicide prevention trials. The FDA needs to systematically monitor postmarketing events by encouraging the development of a validated instrument for postmarketing surveillance of suicidal ideation, behavior, and risk. Over time, the FDA, industry, and clinical researchers should evaluate the impact of the requirement that all central nervous system clinical drug trials must include a Columbia Classification Algorithm of Suicide Assessment (C-CASA)-compatible screening instrument for assessing and documenting the occurrence of treatment-emergent suicidal ideation and behavior. Finally, patients at high risk for suicide can safely be included in clinical trials, if proper precautions are followed. Language: en

As an organism interacts with the world, how good or bad things are at the moment, the value of the current state of the organism, is an important parameter that is likely to be encoded in the brain. As the environment changes and new stimuli appear, estimates of state value must be updated to support appropriate responses and learning. Indeed, many models of reinforcement learning posit representations of state value. We examined how the brain mediates this process by recording amygdala neural activity while monkeys performed a trace-conditioning task requiring fixation. The presentation of different stimuli induced state transitions; these stimuli included unconditioned stimuli (USs) (liquid rewards and aversive air puffs), newly learned reinforcement-predictive visual stimuli [conditioned stimuli (CSs)], and familiar stimuli long associated with reinforcement [fixation point (FP)]. The FP had a positive value to monkeys, because they chose to foveate it to initiate trials. Different populations of amygdala neurons tracked the positive or negative value of the current state, regardless of whether state transitions were caused by the FP, CSs, or USs. Positive value-coding neurons increased their firing during the fixation interval and fired more strongly after rewarded CSs and rewards than after punished CSs and air puffs. Negative value-coding neurons did the opposite, decreasing their firing during the fixation interval and firing more strongly after punished CSs and air puffs than after rewarded CSs and rewards. This representation of state value could underlie how the amygdala helps coordinate cognitive, emotional, and behavioral responses depending on the value of one's state.

Atypical antipsychotic drugs have been used off label in clinical practice for treatment of serious dementia-associated agitation and aggression. Following reports of cerebrovascular adverse events associated with the use of atypical antipsychotics in elderly patients with dementia, the U.S. Food and Drug Administration (FDA) issued black box warnings for several atypical antipsychotics titled "Cerebrovascular Adverse Events, Including Stroke, in Elderly Patients With Dementia." Subsequently, the FDA initiated a metaanalysis of safety data from 17 registration trials across 6 antipsychotic drugs (5 atypical antipsychotics and haloperidol). In 2005, the FDA issued a black box warning regarding increased risk of mortality associated with the use of atypical antipsychotic drugs in this patient population.Geriatric mental health experts participating in a 2006 consensus conference (Bethesda, Md., June 28-29) reviewed evidence on the safety and efficacy of antipsychotics, as well as nonpharmacologic approaches, in treating dementia-related symptoms of agitation and aggression. EVIDENCE/CONSENSUS PROCESS: The participants concluded that, while problems in clinical trial designs may have been one of the contributors to the failure to find a signal of drug efficacy, the findings related to drug safety should be taken seriously by clinicians in assessing the potential risks and benefits of treatment in a frail population, and in advising families about treatment. Information provided to patients and family members should be documented in the patient's chart. Drugs should be used only when nonpharmacologic approaches have failed to adequately control behavioral disruption. Participants also agreed that there is a need for an FDA-approved medication for the treatment of severe, persistent, or recurrent dementia-related symptoms of agitation and aggression (even in the absence of psychosis) that are unresponsive to nonpharmacologic intervention.This article outlines methodological enhancements to better evaluate treatment approaches in future registration trials and provides an algorithm for improving the treatment of these patients in nursing home and non-nursing home settings.

Anticonvulsants are being used clinically as monotherapy and adjuncts in mental illnesses other than affective disorders. This review focuses on the literature for anticonvulsants and lithium in substance use disorders, anxiety disorders, and schizophrenia. Given the abuse potential and other difficulties with prescribing benzodiazepines for alcohol and benzodiazepine withdrawal, anticonvulsants have been considered as an alternative. Promising therapeutic effects have been demonstrated in many of the anxiety disorders, with the greatest number of trials and positive results in posttraumatic stress disorder. Although anticonvulsant and lithium augmentation for schizophrenia is common in practice and has been studied in double-blind, randomized, controlled trials, the sum of the evidence has been inconclusive.

Arab culture, the dominant culture of the central Middle East and the founding culture of Islam, is both a brilliant construction of human creativity and a practical response to many human problems...

Background Treatment studies of depression in residential care are limited. Reports of predictors of response are rare. In the largest nursing home prospective antidepressant trial reported, we examined predictors of response. Methods This was a 12-week open-label study of mirtazapine orally disintegrating tablets performed in 30 US nursing homes. Subjects were men and women aged ≥70, with a Mini Mental State Exam (MMSE) score ≥10, who had a depressive disorder that required antidepressant treatment. Mirtazapine was started at 15 mg at bedtime, and adjusted to 15–45 mg/day. A 16-item Hamilton Depression Rating Scale was used to assess depression at baseline, weeks 2, 4, 8, and 12 or early termination. Results One hundred and twenty-four patients received at least one dose of study drug and of these, 119 had at least one post-drug assessment. Mean age was 82.9 years and 72% were female. Response rates at 12 weeks were 47% on the HAMD and 54% on the CGI. Age, sex, MMSE score, medical burden, history of prior depression, and baseline HAMD severity were not significantly associated with HAMD response (≥50% improvement) and in most cases correlations were trivial

Depression in late life is a disorder that may have disastrous consequences for an individual’s mental and physical health, quality of life, and even take life itself. Many older individuals have suffered from depression in earlier life, and their experience of late-life episodes may confirm a sense of hopelessness and uselessness of this last phase of life. Unlike Erikson’s 1 definition of this final stage of identity in life in which an individual can review and feel accomplishment in past experience, depression may feel like disintegration, crumbling identity, and a wish for an end to all suffering. Late-life depression is potentially a lethal disease. Suicide rates are highest among the elderly 2 and highest in locations where there are more elderly people (e.g., warm resort areas). It is fortunate therefore that modern medicine and psychiatry have techniques for treating depression in late life, and three articles in this issue provide important data regarding treatment with antidepressant medications. Before examining these articles, however, it may be useful to review what we know about late-life depression and its pharmacologic treatment. First, let us examine the diagnosis and prevalence of late-life depression. In many cases, the symptom profile of an elderly depressed individual is not markedly differentfromyoungersufferers.Theretendtobemore physical symptoms and more feelings of decreased self-esteem, worthlessness, and ruminative thinking 3

Atypical antipsychotic drugs are primarily indicated for the treatment of psychotic disorders such as schizophrenia and schizoaffective disorder. Recently, they have also been used for mood stabilization. This article reviews other, potentially therapeutically useful indications for these medications. In most cases, the evidence supporting these new uses is limited but provocative, and involves only case reports. It has not yet been determined whether the usefulness of atypical antipsychotics for nonpsychotic disorders outweighs their potential to cause serious side effects.

To consider the limited usefulness of expert guidelines for teaching psychopharmacology.Potential problems using expert guidelines for teaching psychopharmacology are reviewed.Expert guidelines are an important contribution to the growth of evidence-based psychiatry. As such, they may also be used to teach fundamentals of psychopharmacology. Their use as teaching materials may be limited by their reliance on Diagnostic and Statistical manual of Mental Disorders (DSM) diagnoses, especially for patients with unclear or complicated diagnosing pictures. Biases may also exist in their construction and the data from which they are derived. Other problems include overemphasis on newly released medications and the potential for teaching a "cookbook" approach to psychopharmacology treatment, limiting the development of the "art" of psychopharmacology practice.Although expert guidelines may be a useful tool for teaching psychopharmacology, they also may limit the teaching of psychopharmacology. Comprehensive psychopharmacology training programs that use expert guidelines as teaching tools should emphasize critical reading of clinical trials literature and teaching the use of all psychotropic drugs. Training in the art of psychopharmacology including, nonpharmacological aspects of drug treatment, should also be included.

The objective of this study was to determine whether long-term benzodiazepine use is associated with dose escalation.The authors examined changes in dose and the frequency of dose escalation among new and continuing (at least two years) recipients of benzodiazepines identified from a database containing drug-dispensing and health care use data for all New Jersey Medicaid patients for 39 months. Independent variables included age; Medicaid eligibility category; gender; race or ethnicity; neighborhood socioeconomic variables; chronic illnesses, such as schizophrenia, bipolar illness, panic disorder, and seizure disorder; and predominant benzodiazepine received. Logistic regression analyses were conducted to determine the association between the independent variables and escalation to a high dosage (at least 20 diazepam milligram equivalents [DMEs] per day for elderly patients and at least 40 DMEs per day for younger patients).A total of 2,440 patients were identified, comprising 460 new and 1,980 continuing recipients. Seventy-one percent of continuing recipients had a permanent disability. Among all groups of continuing recipients, the median daily dosage remained constant at 10 DMEs during two years of continuous use. No clinically or statistically significant changes in dosage were observed over time. The incidence of escalation to a high dosage was 1.6 percent. Subgroups with a higher risk of dose escalation included antidepressant recipients and patients who filled duplicate prescriptions for benzodiazepines at different pharmacies within seven days. Elderly and disabled persons had a lower risk of dose escalation than younger patients.The results of this study did not support the hypothesis that long-term use of benzodiazepines frequently results in notable dose escalation.

A computer-based literature search of all antidepressant and electroconvulsive therapy (ECT) treatment studies published between 1995 and September 2001 was conducted. In addition, a review of published chapters, review articles, and metaanalyses was also conducted. Articles were categorized into those reporting comparative studies, those in which the therapeutic agent was not compared with another, articles about ECT, and review articles. These recent publications support the conclusions from prior reviews that antidepressants and ECT are effective and safe treatments for depressed elderly patients. Differences in efficacy and side effects appear to be slight among the various types of antidepressants. Research studies of depressed elderly increased markedly since 1995 compared with all previous years although more studies are still necessary.