Selective serotonin reuptake inhibitor (SSRI) use during pregnancy incurs a low absolute risk for major malformations; however, other adverse outcomes have been reported. Major depression also affects reproductive outcomes. This study examined whether 1) minor physical anomalies, 2) maternal weight gain and infant birth weight, 3) preterm birth, and 4) neonatal adaptation are affected by SSRI or depression exposure. Method: This prospective observational investigation included maternal assessments at 20, 30, and 36 weeks of gestation. Neonatal outcomes were obtained by blinded review of delivery records and infant examinations. Pregnant women (N=238) were categorized into three mutually exclusive exposure groups: 1) no SSRI, no depression (N=131); 2) SSRI exposure (N=71), either continuous (N=48) or partial (N=23); and 3) major depressive disorder (N=36), either continuous (N=14) or partial (N=22). The mean depressive symptom level of the group with continuous depression and no SSRI exposure was significantly greater than for all other groups, demonstrating the expected treatment effect of SSRIs. Main outcomes were minor physical anomalies, maternal weight gain, infant birth weight, pregnancy duration, and neonatal characteristics. Results: Infants exposed to either SSRIs or depression continuously across gestation were more likely to be born preterm than infants with partial or no exposure. Neither SSRI nor depression exposure increased risk for minor physical anomalies or reduced maternal weight gain. Mean infant birth weights were equivalent. Other neonatal outcomes were similar, except 5-minute Apgar scores. Conclusions: For depressed pregnant women, both continuous SSRI exposure and continuous untreated depression were associated with preterm birth rates exceeding 20%.

(Reprinted with permission from the American Journal of Psychiatry 2009; 166:557–566)

(Reprinted with permission from Obstetrics & Gynecology 2008; 111:1001–1020)

(Reprinted with permission from Circulation 2008; 118:1768–1775. © 2008 American Heart Association Inc.)

To review the evidence from randomized clinical trials (RCTs) that have focused on the treatment of patients with Diagnostic and Statistical Manual of Mental Disorders, 4^th Edition (DSM-IV) somatoform disorders. Although somatoform disorders are among the most common mental disorders presenting in the general medical setting, the strength of evidence for specific treatments has not been well synthesized. Methods: MEDLINE search of articles published in English from 1966 to 2006, using the following search terms: randomized clinical trial, somatoform disorders, somatization disorder, undifferentiated somatoform disorder, hypochrondriasis, conversion disorder, pain disorder, and body dysmorphic disorder. Results: A total of 34 RCTs involving 3922 patients were included. Two thirds of the studies involved somatization disorder (n = 4 studies) and lower threshold variants, such as abridged somatization disorder (n = 9) and medically unexplained symptoms (n = 10). Cognitive behavioral therapy (CBT) was effective in most studies (11 of 13), as were antidepressants in a small number (4 of 5) of studies. RCTs examining a variety of other treatments showed benefit in half (8 of 16) of the studies, the most consistent evidence existing for a consultation letter to the primary care physician. Effective treatments have been established for all somatoform disorders except conversion disorder (1 of 3 studies showing benefit) and pain disorder (no studies reported). Conclusion: CBT is the best established treatment for a variety of somatoform disorders, with some benefit also demonstrated for a consultation letter to the primary care physician. Preliminary but not yet conclusive evidence exists for antidepressants.

(Reprinted with permission from Psychosomatic Medicine 2007; 69:881–888)

Executive dysfunction is common after stroke and may impair long-term outcome. Remedies for this condition are limited. Aims: To examine the effect of antidepressants on executive function after stroke. Method: Forty-seven patients who had had a stroke during the prior 6 months received 12 weeks of antidepressant treatment in double-blind placebo-controlled fashion, followed by assessment of executive function at the end of treatment and after 2 years. Results: No significant group effect was found at the end of treatment. However, 21 months after the end of treatment the placebo group showed deterioration of executive function, whereas the active treatment group showed clear and significant improvement independent of depressive symptoms (F =12.1, d.f.= 1.45, P = 0.001). Conclusions: Antidepressant treatment fosters long-term improvement of executive function following stroke. This phenomenon is consistent with a reorganisation of neuronal networks associated with prefrontal functions based on modulation of monoaminergic neurotransmission and the activity of neurotrophins.

(Reprinted with permission from British Journal of Psychiatry 2007; 190: 260–265.)

(Reprinted with permission from Psychiatry 70(4) Winter 2007)

This study examined use of mental health services among adult survivors of Hurricane Katrina in order to improve understanding of the impact of disasters on persons with mental disorders. Methods: A geographically representative telephone survey was conducted between January 19 and March 31, 2006, with 1,043 displaced and nondisplaced English-speaking Katrina survivors aged 18 and older. Survivors who reported serious and mild-moderate mood and anxiety disorders in the past 30 days and those with no such disorders were identified by using the K6 scale of nonspecific psychological distress. Use of services, system sectors, and treatments and reasons for not seeking treatment or dropping out were recorded. Correlates of using services and dropping out were examined. Results: An estimated 31% of respondents (N = 319) had evidence of a mood or anxiety disorder at the time of the interview. Among these only 32% had used any mental health services since the disaster, including 46% of those with serious disorders. Of those who used services, 60% had stopped using them. The general medical sector and pharmacotherapy were most commonly used, although the mental health specialty sector and psychotherapy played important roles, especially for respondents with serious disorders. Many treatments were of low intensity and frequency. Undertreatment was greatest among respondents who were younger, older, never married, members of racial or ethnic minority groups, uninsured, and of moderate means. Structural, financial, and attitudinal barriers were frequent reasons for not obtaining care. Conclusions: Few Katrina survivors with mental disorders received adequate care; future disaster responses will require timely provision of services to address the barriers faced by survivors.

(Reprinted with permission from Psychiatric Services November 2007; 58:1403–1411)

(Reprinted with permission from Journal of Psychiatric Research 2006; 40:1–21)

(Reprinted with permission from Annual Review of Neuroscience; 2000. 23:155–184. Available online at http://arjournals.annualreviews.org/doi/abs/10.1146/annurev.neuro.23.1.155 )

(Reprinted with permission from Journal of Consulting and Clinical Psychology 1999; 67:194–200. Available online at http://psycnet.apa.org/journals/ccp/67/2/194/)

Mild cognitive impairment and cognitive impairment, no dementia, are emerging terms that encompass the clinical state between normal cognition and dementia in elderly people. Controversy surrounds their characterization, definition and application in clinical practice. In this article, we provide physicians with practical guidance on the definition, diagnosis and treatment of mild cognitive impairment and cognitive impairment, no dementia, based on recommendations from the Third Canadian Consensus Conference on the Diagnosis and Treatment of Dementia, held in March 2006. Methods: We developed evidence-based guidelines using systematic literature searches, with specific criteria for study selection and quality assessment, and a clear and transparent decision-making process. We selected studies published from January 1996 to December 2005 that had mild cognitive impairment or cognitive impairment, no dementia, as the outcome. Subsequent to the conference, we searched for additional articles published between January 2006 and January 2008. We graded the strength of evidence using the criteria of the Canadian Task Force on Preventive Health Care. Results: We identified 2483 articles, of which 314 were considered to be relevant and of good or fair quality. From a synthesis of the evidence in these studies, we made 16 recommendations. In brief, family physicians should be aware that most types of dementia are preceded by a recognizable phase of mild cognitive decline. They should be familiar with the concepts of mild cognitive impairment and of cognitive impairment, no dementia. Patients with these conditions should be closely monitored because of their increased risk for dementia. Leisure activities, cognitive stimulation and physical activity could be promoted as part of a healthy lifestyle in elderly people and those with mild cognitive impairment. Vascular risk factors should be treated optimally. No other specific therapies can yet be recommended. Interpretation: Physicians will increasingly see elderly patients with mild memory loss, and learning an approach to diagnosing states such as mild cognitive impairment is now warranted. Close monitoring for progression to dementia, promotion of a healthy lifestyle and treatment of vascular risk factors are recommended for the management of patients with mild cognitive impairment.

(Reprinted with permission from Canadian Medical Association Journal 2008;178(10):1273-85. This work is protected by copyright and the making of this copy was with the permission of Access Copyright. Any alteration of its content or further copying in any form whatsoever is strictly prohibited unless otherwise permitted by law.)

Several predictors of treatment response in late-life depression have been reported in the literature. The aim of this analysis was to develop a clinically useful algorithm that would allow clinicians to predict which patients will likely respond to treatment and thereby guide clinical decision making. Method: A total of 461 patients with late-life depression were treated under structured conditions for up to 12 weeks and assessed weekly with the 17-item Hamilton Rating Scale for Depression (HAM-D-17). The authors developed a hierarchy of predictors of treatment response using signal-detection theory. The authors developed two models, one minimizing false predictions of future response and one minimizing false predictions of future nonresponse, to offer clinicians two clinically useful treatment algorithms. Results: In the first model, early symptom improvement (defined by the relative change in HAM-D-17 total score from baseline to week 4), lower baseline anxiety, and an older age of onset predict response at 12 weeks. In the second model, early symptom improvement represents the principal guide in tailoring treatment, followed by baseline anxiety level, baseline sleep disturbance, and—for a minority of patients—the adequacy of previous antidepressant treatment. Conclusions: Our two models, developed to help clinicians in different clinical circumstances, illustrate the possibility of tailoring the treatment of late-life depression based on clinical characteristics and confirm the importance of early observed changes in clinical status.

(Reprinted with permission from Am J Psychiatry 2008; 165:855–862)

(Reprint w/permission from Journal of Gerontology: PSYCHOLOGICAL SCIENCES 2007, Vol. 62B, No. 1, P3– P11)

(Reprinted with permission from American Journal of Geriatric Psychiatry 2006; 14:95–103)

To review the research on the epidemiology, risk and resiliency, assessment, treatment, and prevention of late-life suicide. Method: I reviewed mortality statistics. I searched MEDLINE and PsycINFO databases for research on suicide risk and resiliency and for randomized controlled trials with suicidal outcomes. I also reviewed mental health outreach and suicide prevention initiatives. Results: Approximately 12/100,000 individuals aged 65 years or over die by suicide in Canada annually. Suicide is most prevalent among older white men; risk is associated with suicidal ideation or behaviour, mental illness, personality vulnerability, medical illness, losses and poor social supports, functional impairment, and low resiliency. Novel measures to assess late-life suicide features are under development. Few randomized treatment trials exist with at-risk older adults. Conclusions: Research is needed on risk and resiliency and clinical assessment and interventions for at-risk older adults. Collaborative outreach strategies might aid suicide prevention.

(Reprinted with permission from Canadian Journal of Psychiatry 2006;51:143–154. https://ww1.cpa-apc.org/Publications/Archives/CJP/2006/march1/heisel-IR.asp)

(Reprinted with permission from Journal of Gerontology : MEDICAL SCIENCES 2003, Vol. 58A, No. 3, 249–265)

There is no consensual definition of "successful aging." Our aim was to review the literature on proportions of subjects meeting criteria and individual components of definitions of successful aging as well as correlates of these definitions. Methods: We conducted a literature search for published English-language peer-reviewed reports of data-based studies of adults over age 60 that included an operationalized definition of successful aging. The authors categorized the components of these definitions and independent variables examined in relation to successful aging (e.g., gender, education, and social contacts). Results: The authors identified 28 studies with 29 different definitions that met our criteria. Most investigations used large samples of community-dwelling older adults. The mean reported proportion of successful agers was 35.8% (standard deviation: 19.8) but varied widely (interquartile range: 31%). Multiple components of these definitions were identified, although 26 of 29 included disability/physical functioning. The most frequent significant correlates of the various definitions of successful aging were age (young-old), nonsmoking, and absence of disability, arthritis, and diabetes. Moderate support was found for greater physical activity, more social contacts, better self-rated health, absence of depression and cognitive impairment, and fewer medical conditions. Gender, income, education, and marital status generally did not relate to successful aging. Conclusion: Despite variability among definitions, approximately one-third of elderly individuals were classified as aging successfully. The majority of these definitions were based on the absence of disability with lesser inclusion of psychosocial variables. Predictors of successful aging varied yet point to several potentially modifiable targets for increasing the likelihood of successful aging.

(Reprinted with permission from American Journal of Geriatric Psychiatry 2006; 14:6–20)

To provide an overview of the role of anxiety disorders in medical illness. Method: The Anxiety Disorders Association of America held a multidisciplinary conference from which conference leaders and speakers reviewed presentations and discussions, considered literature on prevalence, comorbidity, etiology and treatment, and made recommendations for research. Irritable bowel syndrome (IBS), asthma, cardiovascular disease (CVD), cancer and chronic pain were reviewed. Results: A substantial literature supports clinically important associations between psychiatric illness and chronic medical conditions. Most research focuses on depression, finding that depression can adversely affect self-care and increase the risk of incident medical illness, complications and mortality. Anxiety disorders are less well studied, but robust epidemiological and clinical evidence shows that anxiety disorders play an equally important role. Biological theories of the interactions between anxiety and IBS, CVD and chronic pain are presented. Available data suggest that anxiety disorders in medically ill patients should not be ignored and could be considered conjointly with depression when developing strategies for screening and intervention, particularly in primary care. Conclusions: Emerging data offer a strong argument for the role of anxiety in medical illness and suggest that anxiety disorders rival depression in terms of risk, comorbidity and outcome. Research programs designed to advance our understanding of the impact of anxiety disorders on medical illness are needed to develop evidence-based approaches to improving patient care.

(Reprinted with permission from General Hospital Psychiatry 2008; 30:208–225)

(Reprinted with permission from Depression and Anxiety 2008; 25:467–476)

The purpose of this study was to determine the efficacy of panic-focused psychodynamic psychotherapy relative to applied relaxation training, a credible psychotherapy comparison condition. Despite the widespread clinical use of psychodynamic psychotherapies, randomized controlled clinical trials evaluating such psychotherapies for axis I disorders have lagged. To the authors' knowledge, this is the first efficacy randomized controlled clinical trial of panic-focused psychodynamic psychotherapy, a manualized psychoanalytical psychotherapy for patients with DSM-IV panic disorder. Method: This was a randomized controlled clinical trial of subjects with primary DSM-IV panic disorder. Participants were recruited over 5 years in the New York City metropolitan area. Subjects were 49 adults ages 18–55 with primary DSM-IV panic disorder. All subjects received assigned treatment, panic-focused psychodynamic psychotherapy or applied relaxation training in twice-weekly sessions for 12 weeks. The Panic Disorder Severity Scale, rated by blinded independent evaluators, was the primary outcome measure. Results: Subjects in panic-focused psychodynamic psychotherapy had significantly greater reduction in severity of panic symptoms. Furthermore, those receiving panic-focused psychodynamic psychotherapy were significantly more likely to respond at treatment termination (73% versus 39%), using the Multi-center Panic Disorder Study response criteria. The secondary outcome, change in psychosocial functioning, mirrored these results. Conclusions: Despite the small cohort size of this trial, it has demonstrated preliminary efficacy of panic-focused psychodynamic psychotherapy for panic disorder.

(Reprinted with permission from American Journal of Psychiatry 2007; 164:265–272)

(Reprinted with permission from Behaviour Research and Therapy 45 (2007) 1095–1109)

The purpose of this study is to examine the current state of knowledge regarding treating ethnic/racial minority patients with mood and anxiety disorders, emphasizing data-based studies whenever possible. Method: This article reviews the evidence on poorer access and quality of care for minorities, the biological and cultural differences between minority and majority populations that may impact care and outcomes, and recent studies that address minority treatment response and outcomes both alone and in comparison to majority groups. Results: Numerous impediments to appropriately treating anxious and depressed minority patients remain. Underutilization and poor quality of mental health care in minorities is due to less-than-favorable illness and treatment beliefs that affect adherence and outcome, stigma, clinician failure to engage the patient, poor patient activation and biological differences that may impact pharmacotherapy choice. However, though limited in number, some studies do indicate that when appropriate treatment is well-delivered to minorities, results are comparable to those seen among Caucasian patients. Conclusions: The clinician treating members of minority groups must consider differential personal elements, from the biological to the cultural, to achieve treatment success. The limited available data do suggest that minority patients can be successfully treated with available interventions. Of primary importance is for researchers to increase the number of carefully designed intervention studies that allow for ethnic/ racial minority-specific analyses.

(Reprinted with permission from General Hospital Psychiatry 2006; 28:27–36)

Panic disorder can be treated with psychotherapy, pharmacotherapy or a combination of both. Aims: To summarise the evidence concerning the short- and long-term benefits and adverse effects of a combination of psychotherapy and antidepressant treatment. Method: Meta-analyses and meta-regressions were undertaken using data from all relevant randomised controlled trials identified by a comprehensive literature search. The primary outcome was relative risk (RR) of response. Results: We identified 23 randomised comparisons (21 trials involving a total of 1709 patients). In the acute-phase treatment, the combined therapy was superior to antidepressant pharmacotherapy (RR = 1.24, 95% CI 1.02–1.52) or psychotherapy (RR = 1.16, 95% CI 1.03–1.30). After termination of the acute-phase treatment, the combined therapy was more effective than pharmacotherapy alone (RR = 1.61, 95% CI 1.23–2.11) and was as effective as psychotherapy (RR = 0.96, 95% CI 0.79–1.16). Conclusions: Either combined therapy or psychotherapy alone may be chosen as first-line treatment for panic disorder with or without agoraphobia, depending on the patient's preferences.

(Reprinted with permission from British Journal of Psychiatry 2006; 188:305–312)

The authors sought to observe the long-term clinical course of anxiety disorders over 12 years and to examine the influence of comorbid psychiatric disorders on recovery from or recurrence of panic disorder, generalized anxiety disorder, and social phobia. Method: Data were drawn from the Harvard/Brown Anxiety Disorders Research Program, a prospective, naturalistic, longitudinal, multicenter study of adults with a current or past history of anxiety disorders. Probabilities of recovery and recurrence were calculated by using standard survival analysis methods. Proportional hazards regression analyses with timevarying covariates were conducted to determine risk ratios for possible comorbid psychiatric predictors of recovery and recurrence. Results: Survival analyses revealed an overall chronic course for the majority of the anxiety disorders. Social phobia had the smallest probability of recovery after 12 years of follow-up. Moreover, patients who had prospectively observed recovery from their intake anxiety disorder had a high probability of recurrence over the follow-up period. The overall clinical course was worsened by several comorbid psychiatric conditions, including major depression and alcohol and other substance use disorders, and by comorbidity of generalized anxiety disorder and panic disorder with agoraphobia. Conclusions: These data depict the anxiety disorders as insidious, with a chronic clinical course, low rates of recovery, and relatively high probabilities of recurrence. The presence of particular comorbid psychiatric disorders significantly lowered the likelihood of recovery from anxiety disorders and increased the likelihood of their recurrence. The findings add to the understanding of the nosology and treatment of these disorders.

(Reprinted with permission from American Journal of Psychiatry 2005; 162:1179–1187)