Adequate Antidepressant Treatment Research Articles

Depression in elderly patients with Alzheimer dementia or vascular dementia and its infl uence on their quality of life

Background:Alzheimer dementia (AD) and vascular dementia (VD) are the most common causes of dementia in the elderly. Depression is an important co-morbid disorder in these diseases, which is often challenging to recognize. We investigated the prevalence of depression in patients with AD and VD and estimated the influence of depression on the health-related quality of life (HrQoL) in these patients.Materials and Methods:We evaluated prevalence of depression in consecutively recruited patients with AD or VD (n= 98). Depression was diagnosed according to criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and scored using the Geriatric Depression Scale. The EuroQol (EQ-5D and visual analogue scale) was applied to evaluate HrQoL. The severity of cognitive impairment was measured by the Mini-Mental State Examination (MMSE). Multiple regression analysis was used to identify factors predicting severity of depression.Results:The prevalence of depression in AD/VD was 87%. In comparison to the general population, HrQoL measured on the visual analogue scale was reduced by 54% in patients with AD/VD. In the dimension “anxiety/depression” of the EQ-5D, 81% of patients with AD/VD had moderate or severe problems. Depression showed significant association with reduced HrQoL (P<0.01). Independent predictors of more severe depression were older age, male gender, better MMSE scores and being not married.Conclusions:Depression is a prevalent psychiatric co-morbidity in patients with AD/VD, which is often under-diagnosed being masked by cognitive impairment. Depression is a predictor of reduced HrQoL in elder people with AD/VD. Therefore, they should be screened for presence of depressive symptoms and receive adequate antidepressant treatment.

Deep Brain Stimulation for Treatment-Resistant Depression

Brian did reasonably well for about 3 years, with occasional worsening of depressive symptoms but generally with good functioning, when he developed his current major depressive episode. This was his most severe episode to date, with active suicidal ideation with a plan (but no immediate intent) to shoot himself. Over the next year, he had a number of treatments, among them multiple antidepressant medications, including selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, mirtazapine, tricyclic antidepressants, and tranylcypromine, as well as augmentation with lithium, thyroid hormone, buspirone, atypical antipsychotics, anticonvulsants, stimulants, light therapy, and ongoing psychotherapy. No treatment was able to achieve remission or a persistent clinically signifi cant reduction in symptoms. Given his degree of treatment resistance and continued overall deterioration, including increased suicidal ideation, he was referred for ECT. He achieved a good response (50%‐60% symptom reduction) with eight highdose right unilateral ECT treatments. ECT was delivered concurrently with ongoing medications, and attempts were made to optimize medications during and after ECT. However, Brian relapsed in about 6 weeks, and repeat ECT (including four right unilateral and eight bitemporal treatments delivered concurrently with ongoing medications) was unsuccessful in achieving signifi cant symptom reduction but was associated with notable cognitive impairment.

Depression and eating disorders: Treatment and course

BackgroundWe examined the course of major depressive disorder (MDD) and predictors of MDD recovery and relapse in a longitudinal sample of women with eating disorders (ED). Methods246 Boston-area women with DSM-IV anorexia nervosa-restricting (ANR; n=51), AN-binge/purge (ANBP; n=85), and bulimia nervosa (BN; n=110) were recruited between 1987 and 1991 and interviewed using the Eating Disorders Longitudinal Interval Follow-up Evaluation (LIFE-EAT-II) every 6–12months for up to 12years. 100 participants had MDD at study intake and 45 developed MDD during the study. Psychological functioning and treatment were assessed. ResultsTimes to MDD onset (1week–4.3years), recovery (8weeks–8.7years), and relapse (1week–5.2years) varied. 70% recovered from MDD, but 65% subsequently relapsed. ANR patients were significantly less likely to recover from MDD than ANBP patients (p=0.029). Better psychological functioning and history of MDD were associated with higher chance of MDD recovery. Higher baseline depressive severity and full recovery from ED were associated with greater likelihood of MDD relapse; increased weight loss was somewhat protective. Adequate antidepressant treatment was given to 72% of patients with MDD and generally continued after MDD recovery. Time on antidepressants did not predict MDD recovery (p=0.27) or relapse (p=0.26). LimitationsSmall ED diagnostic subgroups; lack of non-ED control group. ConclusionsThe course of MDD in EDs is protracted; MDD recovery may depend on ED type. Antidepressants did not impact likelihood of MDD recovery, nor protect against relapse, which may impact on treatment strategies for comorbid MDD and EDs.

The NeuroStar TMS Device: Conducting the FDA Approved Protocol for Treatment of Depression

The Neuronetics NeuroStar Transcranial Magnetic Stimulation (TMS) System is a class II medical device that produces brief duration, pulsed magnetic fields. These rapidly alternating fields induce electrical currents within localized, targeted regions of the cortex which are associated with various physiological and functional brain changes. In 2007, O'Reardon et al., utilizing the NeuroStar device, published the results of an industry-sponsored, multisite, randomized, sham-stimulation controlled clinical trial in which 301 patients with major depression, who had previously failed to respond to at least one adequate antidepressant treatment trial, underwent either active or sham TMS over the left dorsolateral prefrontal cortex (DLPFC). The patients, who were medication-free at the time of the study, received TMS five times per week over 4-6 weeks. The results demonstrated that a sub-population of patients (those who were relatively less resistant to medication, having failed not more than two good pharmacologic trials) showed a statistically significant improvement on the Montgomery-Asberg Depression Scale (MADRS), the Hamilton Depression Rating Scale (HAMD), and various other outcome measures. In October 2008, supported by these and other similar results, Neuronetics obtained the first and only Food and Drug Administration (FDA) approval for the clinical treatment of a specific form of medication-refractory depression using a TMS Therapy device (FDA approval K061053). In this paper, we will explore the specified FDA approved NeuroStar depression treatment protocol (to be administered only under prescription and by a licensed medical profession in either an in- or outpatient setting).

The NeuroStar TMS Device: Conducting the FDA Approved Protocol for Treatment of Depression

The Neuronetics NeuroStar Transcranial Magnetic Stimulation (TMS) System is a class II medical device that produces brief duration, pulsed magnetic fields. These rapidly alternating fields induce electrical currents within localized, targeted regions of the cortex which are associated with various physiological and functional brain changes.1,2,3 In 2007, O'Reardon et al., utilizing the NeuroStar device, published the results of an industry-sponsored, multisite, randomized, sham-stimulation controlled clinical trial in which 301 patients with major depression, who had previously failed to respond to at least one adequate antidepressant treatment trial, underwent either active or sham TMS over the left dorsolateral prefrontal cortex (DLPFC). The patients, who were medication-free at the time of the study, received TMS five times per week over 4-6 weeks.4 The results demonstrated that a sub-population of patients (those who were relatively less resistant to medication, having failed not more than two good pharmacologic trials) showed a statistically significant improvement on the Montgomery-Asberg Depression Scale (MADRS), the Hamilton Depression Rating Scale (HAMD), and various other outcome measures. In October 2008, supported by these and other similar results5,6,7, Neuronetics obtained the first and only Food and Drug Administration (FDA) approval for the clinical treatment of a specific form of medication-refractory depression using a TMS Therapy device (FDA approval K061053). In this paper, we will explore the specified FDA approved NeuroStar depression treatment protocol (to be administered only under prescription and by a licensed medical profession in either an in- or outpatient setting).

Treatment of Veterans With Depression Who Died by Suicide

To examine the recency and quality of the last Veterans Health Administration (VHA) visit for patients with depression who died by suicide. We obtained services and pharmacy data for all 1,843 VHA patients with diagnosed depressive disorders (DSM-IV criteria) who died by suicide from April 1999 through September 2004. We ascertained the location and timing of their final VHA visit. For visits occurring within 30 days of suicide, we examined 3 quality indicators: (1) evidence that mental illness was a focus of the final visit, (2) adequacy of antidepressant dosage, and (3) recent receipt of mental health services. Just over half of the patients (51%) with depression diagnoses had a VHA visit within 30 days of suicide. A minority of these patients (43%) died by suicide within 30 days of a final visit with mental health services, although 64% had received such services within 91 days of their suicide. Among the 57% of patients who died by suicide within 30 days and who were seen in non-mental health settings for their final visit, only 34% had a mental health condition coded at the final visit, and only 41% were receiving adequate dosages of antidepressant (versus 55% for those last seen by mental health services) (P < .0005). Veterans Health Administration patients with depression who died by suicide within 30 days of their final visit received relatively high rates of mental health services, but most final visits still occurred in non-mental health settings. Increased referrals to mental health services, attention to mental health issues in non-mental health settings, and focus on antidepressant treatment adequacy by all providers might have reduced suicide risks for these patients.

Antidepressant Adequacy and Work Status Among Medicaid Enrollees with Disabilities: A Restriction-based, Propensity Score-adjusted Analysis

Abstract This cross-sectional study of adult survey respondents with disability and depression (n = 199) enrolled in Massachusetts' Medicaid program examined the association of adequately or inadequately prescribed antidepressant treatment and self-reported work status using conditional logistic regression, controlling for age, gender, race, marital status, education, receipt of SSI/SSDI, self-reported disabling condition, and health status. Confounding by severity was addressed by two methods: restriction of our sample and subsequent stratification by propensity score. Individuals receiving adequate antidepressant treatment had an increased odds of working compared to individuals receiving inadequate treatment, both in analyses in which restriction was used to limit confounding (OR = 3.45, 95% CI = 1.15-10.32, P < .03), and in analyses which combined restriction with adjustment by propensity score stratification (OR = 3.04, 95% CI = 1.01-9.62, P < .05). Among this sample of Medicaid enrollees with disability and depression, those receiving adequate antidepressant treatment were significantly more likely to report working.

Cytochrome P450 CYP1A2, CYP2C9, CYP2C19 and CYP2D6 genes are not associated with response and remission in a sample of depressive patients

Cytochrome P450 genes are involved in the metabolism of antidepressants and could influence treatment response. The aim of this study was to investigate the role of allelic variations of the cytochrome P450 CYP1A2, CYP2C9, CYP2C19 and CYP2D6 genes in antidepressant treatment response and remission rates. Two hundred and seventy-eight patients affected by major depression, responders (N = 81) and nonresponders (N=197) to at least one adequate antidepressant treatment, were recruited with a multicentre design for resistant depression and genotyped for all relevant variations. None of the considered metabolic profiles (e.g. poor, intermediate, extensive and ultrarapid metabolizers) was found to be associated with either response or remission rates. In conclusion, the investigated cytochrome genes do not seem to play a major role in antidepressant response in the present sample of depressive patients. Nevertheless, methodological and sample size limitations of this study do not allow definitive conclusions.

Trends in Antidepressant Utilization From 2001 to 2004

This study investigated whether the trend of increasing rates of antidepressant use in the 1990s continued into 2000-2004. Antidepressant treatment rates were examined by age group and by the class of antidepressant in order to identify whether any observed trends were being driven by a particular age group of patients or class of medication. Secondary analysis was performed on data from the 2000-2004 Medical Panel Expenditure Surveys, a nationally representative survey of U.S. households, to examine trends in antidepressant use by age group and medication class in the total sample (N=166,435). Trends in the rates of antidepressant use among individuals with self-reported depression (N=10,959) and self-reported anxiety disorders without comorbid depression (N=6,899) were also examined. Antidepressant use increased among all Americans, from 6.6% in 2000 to 8.1% in 2004 (p<.001). Rates of antidepressant use by individuals with anxiety disorders without comorbid depression increased from 30.8% in 2000 to 39.0% in 2002, before declining to 33.2% in 2004. However, antidepressant use decreased among individuals with self-reported depression, from 63.1% in 2000 to 56.7% in 2004 (p<.001). This downward trend in antidepressant use was largely driven by a decrease in use of selective serotonin reuptake inhibitors, especially among children and middle-aged adults with depression. Rates of adequate antidepressant treatment (defined as receiving at least four antidepressant prescriptions at the minimum adequate daily dosage) peaked in 2002 (36.9%), and there was a significant decline by 2004 (31.7%) (p=.003). After years of increased use of antidepressant therapy to treat depression, a trend reversal in the beginning of the 21st century was observed, including decreasing rates of adequate antidepressant treatment. This downward trend preceded the black-box warnings included on antidepressant labels beginning in 2004.

Treatment-resistant depression: recent developments and future directions

A significant proportion of patients with major depressive disorder (MDD) fail to achieve remission with standard antidepressant therapies, even when optimally delivered. These patients are classified as treatment-resistant depression (TRD), which is distinguished from “difficult-to-treat” depression,[1] defined as depression treated under circumstances that precludes the optimal delivery of a potentially beneficial treatment (e.g., subtherapeutic dosing, intolerable side effects, poor adherence, etc.) TRD is also distinguished from severe depression, as some patients with milder depressive symptoms are markedly treatment resistant, while others with profound, acute depressive symptoms are quite treatment responsive. Defining the boundaries of TRD is critical from a clinical, research, and public health perspective, as drug and device manufacturers seek new regulatory approvals for numerous indications in the TRD spectrum. This article reviews recent developments in TRD, with a focus on classification methods used for regulatory clinical trials; treatments currently approved in the US for TRD; how classification schemes and regulatory rules have limited understanding of their scope of effectiveness; and what changes are needed in research approaches to facilitate novel therapeutic discovery.

Treatment of depressed bipolar patients with alcohol use disorders: Plenty of room for improvement

BackgroundWe aimed to examine the adequacy of antidepressant treatment and compliance with treatment in bipolar patients with and without alcohol use disorders (AUD). We hypothesize that the adequacy of antidepressant treatment and the compliance with treatment for those with AUD are lower than for those without AUD. MethodsSubjects were 97 patients with current bipolar major depressive episode, 39 (40.2%) with lifetime history of AUD and 58 (59.8%) without AUD. Adequacy of antidepressant medication treatment in the 3 previous months was assessed using the Antidepressant Treatment History Form. Compliance rates were estimated. ResultsRates of inadequate treatment were high in all patients. Bipolar patients with AUD (74.3%) showed higher rates of inadequate antidepressant treatment than those without AUD (67.3%). The proportion of intensive treatment was higher in bipolars without AUD (15.5%) than in those with AUD (2.6%). Median compliance was similar in bipolars with and without AUD. LimitationsWe lack serum medication levels to assess the compliance. We do not have data to address the possibility that the presence of AUD adversely affected prescribing practices. ConclusionsBipolars with AUD had lower rates of adequate treatment than those without AUD, but the two groups were not different in terms of self-reported treatment adherence. The finding that bipolar patients with or without comorbid AUD did not receive adequate treatment is of considerable clinical relevance. It raises the question as to whether inadequate treatment of depression contributes to the high rates of morbidity, and attempted and completed suicides in bipolar patient populations.

Predictors of Major Depression Six Months After Admission for Outpatient Treatment

This study examined the rate and predictors of major depression six months after outpatient mental health admission. Assessments were conducted at admission and three and six months later among 166 participants. Antidepressant treatment adequacy and depression outcomes were assessed at follow-ups. Predictors of major depression at six months included nonremission status at three months (odds ratio [OR]=3.56, p=.003), inadequacy of early pharmacotherapy (OR=2.73, p=.009), worse physical functioning measured by the 36-Item Short-Form Health Survey (OR=.975, p<.001), and being unmarried (OR=2.54, p=.031). The findings support the effects of baseline physical disability, marital status, early treatment adequacy, and early remission on the course of major depression. The identification of individuals who do not receive intensive pharmacotherapy or who have not recovered by three months may provide opportunities for interventions to optimize six-month outcomes and to prevent the development of a persistent depression.

Predictors of Major Depression Six Months After Admission for Outpatient Treatment

This study examined the rate and predictors of major depression six months after outpatient mental health admission. Assessments were conducted at admission and three and six months later among 166 participants. Antidepressant treatment adequacy and depression outcomes were assessed at follow-ups. Predictors of major depression at six months included nonremission status at three months (odds ratio [OR]=3.56, p=.003), inadequacy of early pharmacotherapy (OR=2.73, p=.009), worse physical functioning measured by the 36-Item Short-Form Health Survey (OR=.975, p<.001), and being unmarried (OR=2.54, p=.031). The findings support the effects of baseline physical disability, marital status, early treatment adequacy, and early remission on the course of major depression. The identification of individuals who do not receive intensive pharmacotherapy or who have not recovered by three months may provide opportunities for interventions to optimize six-month outcomes and to prevent the development of a persistent depression.

Does the Duration of Index Episode Affect the Treatment Outcome of Major Depressive Disorder?

This article aims to identify baseline sociodemographic and clinical characteristics associated with the duration of the index major depressive episode (MDE) and to assess the effect of the current MDE duration on response and remission rates with up to 14 weeks of citalopram. Eligible participants met DSM-IV criteria for nonpsychotic major depressive disorder, scored >or= 14 on the 17-item Hamilton Rating Scale for Depression (HAM-D-17), and were not resistant to adequate antidepressant treatment in the current episode. The first patient was enrolled in July 2001 and the last visit for the last patient in follow-up was in March 2006. The evaluable sample (N = 2851) was divided into 4 groups based on the index MDE duration at study entry: acute (<or= 6 months, N = 1324), subchronic (7-23 months, N = 807), chronic (24-41 months, N = 326), and ultrachronic (>or= 42 months, N = 394). These 4 groups were compared in terms of baseline sociodemographic and clinical characteristics and treatment outcomes. Citalopram was generally begun at 20 mg/day and raised to 40 mg/day by weeks 2 through 4 and to 60 mg/day (final dose) by weeks 4 through 6. Logistic regression models with adjusted post hoc analyses were used to control for associated baseline characteristics. Response was defined as >or= 50% reduction in baseline 16-item Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR-16) scores at exit. Remission was defined as <or= 7 on the HAM-D-17 or <or= 5 on the QIDS-SR-16. MDE duration was longer in primary care settings, blacks, Hispanics, single or widowed, unemployed, publicly insured or uninsured, older, and less educated participants and in those with lower income, less recurrence, or greater concurrent general medical or Axis I comorbidities. HAM-D-17 remission rates ranged from 31.0% (acute group) to 24.1% (ultrachronic group). HAM-D-17 remission rates were significantly related to MDE duration (p = .0010), but after adjustments for baseline differences among the 4 groups, remission rates were not different. QIDS-SR-16 response rates were lower for the subacute and chronic groups but not different for the acute and ultrachronic groups after adjustment. Longer MDE duration is associated with socioeconomic disadvantage and greater Axis I and medical comorbidity. Episode duration per se does not significantly affect the likelihood of remission. clinicaltrials.gov Identifier: NCT00021528.

Adequacy of, Attitudes Toward, and Adherence to Treatments by Suicidal and Nonsuicidal Depressed Patients

We examined differences in treatments received, and attitudes and adherence to them between suicidal and nonsuicidal patients with major depressive disorder (MDD). Psychiatric MDD patients with no suicidal behavior (N = 92), suicidal ideation (N = 92), or attempts (N = 34) were compared during 6 months of follow-up in the Vantaa Depression Study (VDS). Patients with suicidal behavior received antidepressants or adequate antidepressant treatment significantly more often, had more frequent appointments with psychiatrists, more psychotherapeutic support, and more favorable attitudes toward antidepressant treatment than nonsuicidal patients. However, after adjusting for the confounding severity of depression, the significance of these differences was lost. Adherence to treatment was similar in the patient groups. Overall, among psychiatric patients with MDD, those known to be suicidal have higher suicide risk and should receive more intensive treatment. However, suicidal behavior per se does not seem to markedly influence treatments provided nor should it be associated with negative attitudes or poor adherence to treatments.

May duration of untreated illness influence the long-term course of major depressive disorder?

The aim of this naturalistic study was to investigate the possible influence of the duration of untreated illness (DUI) on the long-term course of Major Depressive Disorder (MDD). One hundred and thirteen patients with recurrent MDD, according to DSM-IV-TR criteria, followed up for 5 years, were selected, interviewed and their clinical charts were reviewed. The DUI was defined as the interval between the onset of the first depressive episode and the first adequate antidepressant treatment. The sample was divided into two groups according to the DUI: one group with a DUI ≤ 12 months ( n = 75), and the other with a DUI > 12 months ( n = 38). The main demographic and clinical course variables were compared between the two groups using Student's t-tests or chi-square tests. Patients with a longer DUI showed an earlier age at onset ( t = 2.82, p = 0.006) and a longer duration of illness ( t = 3.20, p = 0.002) compared to patients with a shorter DUI. In addition, the total number of depressive episodes occurring before the first antidepressant treatment was higher in the group with a longer DUI ( t = −2.223, p < 0.03). Even though limited by the retrospective nature of the study, these preliminary findings would suggest that a longer DUI may negatively influence the course of MDD. Larger prospective studies are warranted to further investigate the role of the DUI within MDD.

Adequacy of Antidepressant Treatment in Spanish Primary Care: A Naturalistic Six-Month Follow-Up Study

This study evaluated the adequacy of pharmacological antidepressant treatment in major depressive episodes prescribed in 16 Spanish primary care centers, both during the acute phase of treatment and after the first three months of the continuation phase, under real-world naturalistic conditions (usual care). Factors that could be associated with adequacy of care also were explored. A total of 333 patients from primary care who began pharmacological antidepressant treatment were followed up for six months. Treatment adequacy and associated factors were evaluated. Between 27% and 32% of patients received adequate antidepressant treatment during the acute phase. Percentages of adequacy were between 21% and 25% when considering the acute phase and the first three months of the continuation phase. Psychiatric consultations were found to be associated with treatment adequacy. In state-funded Spanish primary care centers, antidepressant treatment adequacy was poor during both the acute phase and the first three months of the continuation phase. Primary care physicians prescribed suggested antidepressants, mostly as recommended (99%) and at adequate dosages. However, they did not perform the recommended number of follow-up sessions and treated patients with depressive disorders other than major depression as if they had a major depressive episode. Collaborative interventions between primary and specialized care could improve treatment adequacy.

Adequacy of Antidepressant Treatment in Spanish Primary Care: A Naturalistic Six-Month Follow-Up Study

Adequacy of Antidepressant Treatment in Spanish Primary Care: A Naturalistic Six-Month Follow-Up Study

Duration of untreated illness in major depressive disorder: a naturalistic study

Most of the studies on the duration of untreated illness (DUI) as a possible predictor of the clinical outcome and the course have focused on the psychotic disorders. The present naturalistic study was aimed to evaluate the possible relationship between the DUI and some clinical characteristics of a sample of patients with major depressive disorder (MDD). Sixty-eight patients with MDD, according to the Diagnostic and Statistical Manual of Mental Disorders, IV Edition, Text Revision (DSM-IV-TR) criteria, followed-up for 4 years, were selected, interviewed and their clinical charts reviewed. The DUI was defined as the interval between the onset of the first major depressive episode and the first adequate antidepressant treatment. The sample was divided in two groups according to a DUI <or= 12 months (n = 45) and > 12 months (n = 23). The main demographic and clinical course variables were compared between the two groups using t-tests or chi-squared tests. Patients with a DUI > 12 months were more frequently women (chi2 = 4.005, p = 0.045), had an earlier onset (t = 2.515, p = 0.014), a longer duration of illness (t = -2.483, p = 0.016), a higher number of recurrences (t = -2.262, p = 0.027) and had more frequently comorbid Axis I disorders with onset later than MDD (chi2 = 5.595, p = 0.05). These findings suggest that a longer DUI may negatively influence the clinical course of MDD. Further studies on larger samples are warranted to confirm these preliminary results.

Primary care doctor attributions for why patients did not receive adequate antidepressant treatment

Journal of Evaluation in Clinical PracticeVolume 13, Issue 3 p. 473-475 Primary care doctor attributions for why patients did not receive adequate antidepressant treatment Paul A. Pirraglia MD MPH, Corresponding Author Paul A. Pirraglia MD MPH Assistant Professor of Medicine, Health Services Research & Development Program to Integrate Psychosocial and Health Services in Chronic Diseases and Disability, Providence VA Medical Center and Brown University, Providence, RI, USAPaul A. PirragliaProvidence VA Medical Center830 Chalkstone Ave., Bldg. T32Providence, RI 02908-4799USAE-mail: [email protected]Search for more papers by this authorVyshali Murthy BA, Vyshali Murthy BA Data Analyst,Search for more papers by this authorJeffrey B. Weilburg MD, Jeffrey B. Weilburg MD Assistant Professor of Psychiatry, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USASearch for more papers by this author Paul A. Pirraglia MD MPH, Corresponding Author Paul A. Pirraglia MD MPH Assistant Professor of Medicine, Health Services Research & Development Program to Integrate Psychosocial and Health Services in Chronic Diseases and Disability, Providence VA Medical Center and Brown University, Providence, RI, USAPaul A. PirragliaProvidence VA Medical Center830 Chalkstone Ave., Bldg. T32Providence, RI 02908-4799USAE-mail: [email protected]Search for more papers by this authorVyshali Murthy BA, Vyshali Murthy BA Data Analyst,Search for more papers by this authorJeffrey B. Weilburg MD, Jeffrey B. Weilburg MD Assistant Professor of Psychiatry, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USASearch for more papers by this author First published: 18 May 2007 https://doi.org/10.1111/j.1365-2753.2006.00788.xRead the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Volume13, Issue3June 2007Pages 473-475 RelatedInformation