Subsyndromal States Research Articles

Brief Research Report: A Pilot Study of Cognitive Behavioral Regulation Therapy (CBT-REG) for Young People at High Risk of Early Transition to Bipolar Disorders.

Attempts to increase early identification of individuals in the early stages of bipolar disorders (i.e., individuals at high risk of bipolar disorders and/or experiencing a subthreshold syndrome with bipolar symptoms) have highlighted the need to develop high benefit-low risk interventions. We suggest that any new psychological therapy should (i) be acceptable to young people seeking help for the first time, (ii) be applicable to “at risk” conditions and sub-syndromal states and (iii) consider pluripotent factors that may be linked to illness progression not only for bipolar disorders specifically but also for other potential disease trajectories. However, evidence indicates that current interventions for youth with emerging mood disorders mainly represent approaches abbreviated from “disorder-specific” therapies used with older adults and are primarily offered to first episode cases of bipolar disorders who are also receiving psychotropic medication. This brief report discusses empirical findings used to construct core targets for therapeutic interventions that might reduce or delay transition to full-threshold bipolar disorders. We describe an intervention that includes strategies for problem-solving, reducing sleep-wake cycle disturbances, self-management of rumination and that addresses the needs of individuals with “sub-threshold” presentations who are probably at risk of developing a bipolar or other major mental disorders. Outcome data from a case series of 14 youth indicates that the intervention appears to demonstrate a relatively high benefit-to-risk ratio, promising levels of engagement with the therapy modules, and the therapy appears to be acceptable to a wide range of help-seeking youth with early expressions of bipolar psychopathology.

Identifying Electrophysiological Prodromes of Post-traumatic Stress Disorder: Results from a Pilot Study.

The objective of this research project is the identification of a physiological prodrome of post-traumatic stress disorder (PTSD) that has a reliability that could justify preemptive treatment in the sub-syndromal state. Because abnormalities in event-related potentials (ERPs) have been observed in fully expressed PTSD, the possible utility of abnormal ERPs in predicting delayed-onset PTSD was investigated. ERPs were recorded from military service members recently returned from Iraq or Afghanistan who did not meet PTSD diagnostic criteria at the time of ERP acquisition. Participants (n = 65) were followed for up to 1 year, and 7.7% of the cohorts (n = 5) were PTSD-positive at follow-up. The initial analysis of the receiver operating characteristic (ROC) curve constructed using ERP metrics was encouraging. The average amplitude to target stimuli gave an area under the ROC curve of greater than 0.8. Classification based on the Youden index, which is determined from the ROC, gave positive results. Using average target amplitude at electrode Cz yielded Sensitivity = 0.80 and Specificity = 0.87. A more systematic statistical analysis of the ERP data indicated that the ROC results may simply represent a fortuitous consequence of small sample size. Predicted error rates based on the distribution of target ERP amplitudes approached those of random classification. A leave-one-out cross validation using a Gaussian likelihood classifier with Bayesian priors gave lower values of sensitivity and specificity. In contrast with the ROC results, the leave-one-out classification at Cz gave Sensitivity = 0.65 and Specificity = 0.60. A bootstrap calculation, again using the Gaussian likelihood classifier at Cz, gave Sensitivity = 0.59 and Specificity = 0.68. Two provisional conclusions can be offered. First, the results can only be considered preliminary due to the small sample size, and a much larger study will be required to assess definitively the utility of ERP prodromes of PTSD. Second, it may be necessary to combine ERPs with other biomarkers in a multivariate metric to produce a prodrome that can justify preemptive treatment.

Emotional reactivity, functioning and chronic inflammation in remitted bipolar patients: Clinical relevance of a dimensional approach

Aims To examine emotional reactivity (ER) as a dimension that may contribute to the better characterization of subsyndromal mood symptoms in bipolar disorder (BD) patients during remission, and to explore the association between ER, psychosocial functioning and levels of C-reactive protein (CRP, a biomarker of low-grade inflammation) including as to whether CRP is a biosignature of ER in BD. Method Six hundred and thirteen adult BD outpatients. Assessments: psychosocial functioning by Functional Assessment Short Test (FAST),mood by Multidimensional Assessment of Thymic States(MAThyS). The MAThyS ER sub-score (0–40) characterized 3 patients: – – 16–24: normal emotional reactivity (NormalER); – >24: emotional hyperreactivity (HyperER). CRP was measured by using standard enzyme immunoassay. Statistical analyses were performed using SPSS v21. Results HypoER ( n =144; m =12.4±3.4), NormalER ( n =198; m =19.9±2.6); HyperER ( n =271; m =28.9±3.7). BD patients with HypoER or HyperER had significantly greater levels of residual mood symptoms than patients with NormalER ( P m =21±14.1) or HyperER (FAST m =20±11.2 presented lower functioning ( P m =2.8±2.0; P m =4.3±2.8; P m =1.4±1.4). Conclusions ER appear to impact psychosocial functioning as well as to be a pertinent dimension to discriminate subsyndromal mood states in remitted BD patients. CRP could be a biological validator of emotional reactivity in BD. Association between ER-CRP may be useful proxy to examine the relationship between specific symptom profiles and chronic inflammation, a potential biological state associated with BD. These novel findings could be clinically relevant, if tested and confirmed by future studies.

Subsyndromal States in Bipolar Disorder

BACKGROUND:Despite adequate treatment, patients with bipolar disorder suffer from subsyndromal symptoms. This study has been done to see the association of subsyndromal symptoms with age of onset, duration of illness, duration of episodes, and number of episodes.AIMS:To know the prevalence of subsyndromal symptoms and their relationship with age of onset, total duration of illness, number of episodes, and duration of episodes in patients with bipolar disorder in remission.MATERIALS AND METHODS:The study was cross sectional and hospital based. One hundred patients, aged between 18 and 65 years, diagnosed as bipolar disorder according to Research Diagnostic Criteria of ICD-10, and with good compliance with the prophylactic medications, score of ≤5 on Beck's Mania Rating Scale (BMRS) and score ≤8 on Hamilton Depression Rating Scale (HDRS) were recruited by the purposive sampling method. Descriptive statistics were used to describe various sample characteristics. Group differences for categorical variables were examined with the chi-square test, whereas an independent 't' test was used for continuous variables.RESULTS:The most common manic symptom was a decrease in sleep (49%), followed by an increase in verbal activity (39%), hostility (37%), and increase in motor activity (33.33%). The subsyndromal manic group had a lower age of onset (58.8%), males (82.4%), unemployed (23.5%), educated (80.4%). There was no significant difference between with and without subsyndromal mania groups with respect to age, age of onset, duration of illness, number of episode, and average duration of episode.CONCLUSION:Subsyndromal manic symptoms are prevalent and have no relationship with current age, age of onset of illness, duration of illness, number of episode, and average duration of illness in patient with bipolar disorder in remission.

Metabolic syndrome in drug-naïve and drug-free patients with schizophrenia and in their siblings

ObjectivesWe tested the hypothesis that metabolic disturbances in people with schizophrenia exist as a part of the schizophrenic syndrome, even when the antipsychotic drug effect is eliminated. We aimed to determine the prevalence of metabolic syndrome among patients with schizophrenia who were antipsychotic drug-naive or drug-free and their siblings for comparison with healthy controls. MethodsOne-hundred-two patients with schizophrenia (drug-naïve or drug-free), 64 siblings and 70 age-matched healthy subjects were recruited for this case–control study. Metabolic syndrome was assessed based on Adult Treatment Panel (ATP) III, adapted ATP III and International Diabetes Federation criteria. Student's t-tests, chi-squared tests, Kruskal–Wallis tests and Bonferroni corrections were used as appropriate. ResultsThe diagnoses of metabolic syndrome and metabolic disturbances as a subsyndromal state were found to be significantly more frequent in patients and their siblings than in the controls. Low levels of high-density lipoprotein cholesterol and disturbances in blood pressure put the patient group at risk for metabolic syndrome even before they were exposed to antipsychotic drugs. ConclusionsAlthough antipsychotic drugs have consistently been related to disturbances of glucose and lipid metabolism in patients with schizophrenia, this study showed that patients with schizophrenia and their siblings are already at a high risk for metabolic syndrome independent of any antipsychotic effects. These individuals should be monitored regularly following a diagnosis of schizophrenia.

Delirium: A disorder of consciousness?

Delirium is recognised as a disorder of consciousness, however, no evidence has been previously generated to specifically address this premise. In order to evaluate this established notion, we have attempted to review consciousness, the components of consciousness and the emerging evidence for neuroanatomical correlates and then relate this to the recognized features of delirium. We have established that the level of awareness is modulated by alertness and arousal, focused by attention and has the ability to switch between the personal resonances of the experience to the precision of cognition. We have discussed consciousness’s relationship with delirium and how the degree of integration of CNS function is mandatory for realisation of higher order function and this has implications for the conceptualisation and management of delirium. We have explored the understanding of downstream, components of consciousness as not giving rise to the full condition of delirium but as a subsyndromal state. We have argued that there is a need for future diagnostic criteria, such as DSM-V, to operationalize disturbance of consciousness together with non-cognitive manifestations of delirium.Intervention studies in delirium have focussed on drugs that improve memory (cholinesterase inhibitors). If memory is only one element of consciousness then we reason instead on evaluating the determinants of consciousness that may be modifiable, such as awareness. Reinforcement of environmental awareness by managing a patient within a low stimulus or familiar surrounding may therefore offer a therapeutic intervention.Overall there seemed support for, or no evidence against, the belief that delirium is a disorder of consciousness. From Descartes ‘I think therefore I am’ we can say ‘I am aware not therefore delirious I am’.

To cure sometimes, to relieve often, to comfort always.

Schizophrenia is a severe mental disorder that affects approximately 1% of the population worldwide. It is associated with major clinical and psychosocial morbidity and places significant burden on the affected individuals, their families and society.[1] Research in the past two decades has convincingly demonstrated that tertiary prevention in schizophrenia is possible and that decreasing the delay in the initiation of treatment can improve clinical and functional outcomes.[2] This finding has led to increased interest in testing the feasibility of secondary prevention focussed on individuals who are at high-risk of developing schizophrenia. In an attempt to capture the clinical profiles of such individuals, different operationalized definitions have been proposed such as At Risk Mental States (ARMS), Attenuated Psychotic Symptoms (APS), Brief Limited Intermittent Psychotic Symptoms(BLIPS), Ultra High Risk Individuals (UHR),[3]–[5] Early Initial Prodromal States (EIPS) and Late Initial Prodromal States (LIPS).[6] The common theme across these definitions is the presence of functional impairment and subthreshold psychotic symptoms. The forum piece by Zhao and colleagues[7] mentions one of these on-going efforts: the psychosis task force of the American Psychiatric Association (APA) had considered the inclusion of ‘Attenuated Psychosis Syndrome’(APS) as a new diagnostic entity in DSM-5 (www.dsm5.org). Many studies have been conducted to validate these concepts.[4],[5] The emerging consensus is that the predictive validity of the high-risk status is poor since, regardless of the definition used, less than 40% of individuals considered high-risk will convert to syndromal schizophrenia or a schizophrenia spectrum disorder.[5],[7],[8] Moreover, the reported conversion rates are lower in the more recent publications.[7] A considerable percentage of non-converters (15-54%) remit fully;[8] the remainder are likely to be diagnosed later with non-psychotic disorders, particularly anxiety disorders and substance use disorders.[9] In addition, the reliability of the APS in theDSM-5 field trial[10] was poor; screening of unselected psychiatric patients using the APS criteria did not result in the identification of a unique clinical population.[11] Finally, epidemiological studies have suggested that psychotic-like experiences, when present in young individuals, are usually transitory and may be considered a variation in normal developmental trajectories.[12] A fundamental argument for adopting any formal clinical diagnosis is that there is a ‘sufficient amount of etiological and prognostic homogeneity among patients belonging to a given diagnostic group so that the assignment of a patient to this group has probability implications which it is clinically unsound to ignore’.[13] It could be argued that none of the definitions for subsyndromal psychotic states used to date satisfies this fundamental principal and, therefore, that the clinical utility of APS and related syndromes remains questionable. There are eight studies that have focused on the effect of pharmacological, psychological, or combination treatments on the clinical and functional outcomes of individuals considered at high risk for schizophrenia[5],[14],[15] Taken together, these studies suggest that focused treatment is modestly effective in reducing the rates of conversion to psychosis compared to no treatment or treatment as usual (Relative Risk=0.36; 95%CI: 0.22-0.59).[14] However, this advantage appears to dissipate 2-3 years following treatment cessation.[5],[14] Unfortunately, the heterogeneity of the interventions used in these studies makes it impossible to arrive at any evidence-based recommendation for a specific type of treatment. Nevertheless, all of the interventions led to some degree of symptomatic improvement.[5],[14] In summary, it could be argued that efforts to identify ‘prodromal schizophrenia’ have largely failed. Focused interventions in people currently identified as high-risk for schizophrenia, be they pharmacological or psychological, have failed to produce the disease-modifying results hoped for. Thus, early intervention for secondary prevention for schizophrenia remains beyond our reach. In a climate of limited (and in many cases reducing) treatment resources for chronic mental health disorders such as schizophrenia, having separate services for high-risk individuals may prove a public health experiment that we cannot afford to support. Nevertheless, help-seeking patients with psychotic features deserve our attention and care even when they do not fulfil any diagnostic criteria.

Differentiation of various forms of depression.

There will likely be a day sometime in the future that psychiatric diagnoses will be made by laboratory tests, as is already the case for many diagnoses in internal medicine. Until that time, however, it is the clinical acumen of the psychiatrist and his or her ability to obtain a complete and accurate history that leads to a diagnosis. It is very clear that what is considered ‘depression’ is a variety of disorders that will likely respond to a variety of treatments. The definition of major depressive disorder is an arbitrary definition which arose from the concept of ‘primary affective disorder’ as developed at Washington University in St. Louis in the 1960s. The criteria for primary affective disorder involved a mood change and a grouping of symptoms that lasted four weeks or longer. It was found that the symptoms differentiated depressed patients from patients with medical and other psychiatric conditions. The use of symptom-based diagnostic criteria was quite novel in psychiatry in the 1960s but this approach became widely accepted and subsequently resulted in the formulation of DSM III. The criteria for major depressive disorder have largely been unchanged since 1980 when DSM III was first published. Other forms of depression, particularly dysthymic disorder, were included in DSM III in order to provide a diagnostic template for various forms of depression which did not meet the precise definition for major depressive disorder. Additional forms of depression, such as recurrent brief depression and minor depression, were also included in DSM III and subsequent revisions, with the provision that further research needed to be done to better define these conditions so that they might be included as distinct entities. The two forum commentaries published in this issue of the Shanghai Archives of Psychiatry by Zhenghui Yi and Yiru Fang[1] and by Jianlin Ji[2] attempt to better define depressions that don't meet criteria for major depressive disorder. These studies are interesting because they propose changes in how subsyndromal forms of depression are defined. The comment by Yi and Fang cites a study from China which reports that the symptoms of subsyndromal depression in Chinese subjects are somewhat different than those in subjects with typical major depressive disorder and that these subsyndromal symptoms may result in presentation in a medical rather than a psychiatric setting. They also point to the possibility of biological markers to better identify individuals with subsyndromal depression. Over 40 years ago, Robins and Guze[3] proposed that the differentiation of psychiatric conditions be based on multiple factors. These factors included clinical description, family history, the course of the disorder, treatment response, and biological or laboratory differences. Unfortunately, to date there have been very few biological or laboratory differences that help to differentiate among the psychiatric conditions and thus a clinician must make a clinical decision about how best to classify the disorder that the patient presents with. The comments by Yi and Fang[1] and by Ji[2] on the need to differentiate subsyndromal depressive states are of interest because they highlight the importance of identifying biological markers of these conditions. These efforts to further define subtypes of depression are commendable and illustrate the advances in research that we have experienced since the seminal Robins and Guze article and the development of DSM III.

Six‐month functional outcome of a bipolar disorder cohort in the context of a specialized‐care program

A marked disparity between functional recovery and symptomatic improvement has been demonstrated in bipolar disorder. However, most of the previous studies have been conducted in the United States, and there is little prospective research from Europe on this topic. The main objective of the present six-month follow-up study was to assess functioning in a sample of Spanish bipolar disorder patients following an acute episode or subsyndromal state. Additionally, we also evaluated the sensitivity to change of the Functioning Assessment Short Test (FAST). A total of 97 bipolar disorder patients with syndromal (n = 59) or subsyndromal (n = 38) symptoms were evaluated using the 17-item Hamilton Depression Rating Scale and Young Mania Rating Scale. The FAST was the primary measure to assess multiple areas of psychosocial functioning. Functioning was evaluated at four different time periods: baseline, 21 days, three months, and six months. A significant improvement in global functioning was found in the whole sample over the six-month period, as indicated by a reduction of FAST total score (mean ± standard deviation) from 39.97 ± 15.10 to 30.65 ± 16.93 (F = 36.104, p = 0.0001). This was also evident in all areas of functioning studied. However, only 26.4% of remitted patients (n = 42) achieved functional recovery, while 79.6% of the total sample (N = 97) experienced clinical remission of acute symptoms. Although many patients presented syndromal recovery, only a minority of them achieved favorable functioning in multiple areas, even after specialized mental health care. Furthermore, the FAST scale was sensitive to detect minimal changes in functioning in both short (21 days) and long (6 months) periods, which may be relevant to the use of this scale in clinical trials.

Late life depression and incident activity limitations: Influence of gender and symptom severity

Mental disorders, especially depression, are one of the principal causes of disablement. Previous research has been limited partly due to the failure to take into account sub-syndromal states and the very large number of candidate mediating and confounding factors. Longitudinal associations between baseline depressive symptomatology and activity limitations were examined in a community-dwelling elderly cohort of 3191 participants. Mixed logistic models were used to determine associations between mild or severe depressive symptoms (Center for Epidemiologic Studies-Depression Scale, CES-D), and 7-year incident disability on four limitation scales assessing instrumental and basic activities of daily living, mobility using the Rosow and Breslau scale, and social restriction. In men, mild depressive symptomatology was associated with increased incident limitations on instrumental activities of daily living (IADL) (odds ratio (OR) (95% CI)=5.07 (2.25-11.42)). In women, severe depressive symptomatology was related to social restriction (OR (95% CI)=2.36 (1.31-4.25)), IADL (OR (95% CI)=1.89 (1.13-3.15)) and activities of daily living (OR (95% CI)=11.15 (3.43-36.23)). Men and women with a 2-year increase in CES-D score were highly at risk for social restriction and limitations in mobility and IADL. Depression is an independent predictor of disability in the elderly population; the relation is gender-dependent and varies with symptom load.

Course and Impact of Bipolar Disorder in Young Patients

The presentation of bipolar disorder in children and adolescents may vary from its presentation in adults. Rage, irritability, and long episodes are common manifestations of mania in young people with bipolar disorder. Frequent comorbid disorders in young patients include ADHD and anxiety disorders. Prodromal and subsyndromal states of bipolar disorder, such as bipolar disorder NOS, present opportunities for early intervention and prevention. Early recognition and intervention are crucial, because untreated pediatric bipolar disorder becomes chronic, has a high incidence of relapse, and has a poor prognosis.

Subsyndromal states in bipolar disorder

Background:Despite adequate treatment, patients with bipolar disorder suffer from subsyndromal symptoms. This study has been done to see the association of subsyndromal symptoms with age of onset, duration of illness, duration of episodes, and number of episodes.Aims:To know the prevalence of subsyndromal symptoms and their relationship with age of onset, total duration of illness, number of episodes, and duration of episodes in patients with bipolar disorder in remission.Materials and Methods:The study was cross sectional and hospital based. One hundred patients, aged between 18 and 65 years, diagnosed as bipolar disorder according to Research Diagnostic Criteria of ICD-10, and with good compliance with the prophylactic medications, score of ≤5 on Beck’s Mania Rating Scale (BMRS) and score ≤8 on Hamilton Depression Rating Scale (HDRS) were recruited by the purposive sampling method. Descriptive statistics were used to describe various sample characteristics. Group differences for categorical variables were examined with the chi-square test, whereas an independent ‘t’ test was used for continuous variables.Results:The most common manic symptom was a decrease in sleep (49%), followed by an increase in verbal activity (39%), hostility (37%), and increase in motor activity (33.33%). The subsyndromal manic group had a lower age of onset (58.8%), males (82.4%), unemployed (23.5%), educated (80.4%). There was no significant difference between with and without subsyndromal mania groups with respect to age, age of onset, duration of illness, number of episode, and average duration of episode.Conclusion:Subsyndromal manic symptoms are prevalent and have no relationship with current age, age of onset of illness, duration of illness, number of episode, and average duration of illness in patient with bipolar disorder in remission.

GABAA‐benzodiazepine receptor availability in smokers and nonsmokers: Relationship to subsyndromal anxiety and depression

Many smokers experience subsyndromal anxiety symptoms while smoking and during acute abstinence, which may contribute to relapse. We hypothesized that cortical gamma aminobutyric acid(A)-benzodiazepine receptor (GABA(A)-BZR) availability in smokers and nonsmokers might be related to the expression of subsyndromal anxiety, depressive, and pain symptoms. Cortical GABA(A)-BZRs were imaged in 15 smokers (8 men and 7 women), and 15 healthy age and sex-matched nonsmokers, and 4 abstinent tobacco smokers (3 men; 1 woman) using [(123)I]iomazenil and single photon emission computed tomography (SPECT). Anxiety and depressive symptoms were measured using the Spielberger's State-Trait Anxiety Index (STAI) and the Center for Epidemiology Scale for Depressive Symptoms (CES-D). The cold pressor task was administered to assess pain tolerance and sensitivity. The relationship between cortical GABA(A)-BZR availability, smoking status, and subsyndromal depression and anxiety symptoms, as well as pain tolerance and sensitivity, were evaluated. Surprisingly, there were no statistically significant differences in overall GABA(A)-BZR availability between smokers and nonsmokers or between active and abstinent smokers; however, cortical GABA(A)-BZR availability negatively correlated with subsyndromal state anxiety symptoms in nonsmokers but not in smokers. In nonsmokers, the correlation was seen across many brain areas with state anxiety [parietal (r = -0.47, P = 0.03), frontal (r = -0.46, P = 0.03), anterior cingulate (r = -0.47, P = 0.04), temporal (r = -0.47, P = 0.03), occipital (r = -0.43, P = 0.05) cortices, and cerebellum (r = -0.46, P = 0.04)], trait anxiety [parietal (r = -0.72, P = 0.02), frontal (r = -0.72, P = 0.02), and occipital (r = -0.65, P = 0.04) cortices] and depressive symptoms [parietal (r = -0.68; P = 0.02), frontal (r = -0.65; P = 0.03), anterior cingulate (r = -0.61; P = 0.04), and temporal (r = -0.66; P = 0.02) cortices]. The finding that a similar relationship between GABA(A)-BZR availability and anxiety symptoms was not observed in smokers suggests that there is a difference in GABA(A)-BZR function, but not number, in smokers. Thus, while subsyndromal anxiety and depressive symptoms in nonsmokers may be determined in part by GABA(A)-BZR availability, smoking disrupts this relationship. Aberrant regulation of GABA(A)-BZR function in vulnerable smokers may explain why some smokers experience subsyndromal anxiety and depression.

Epidemiology of subtypes of depression

There is a general clinical impression that depression differs qualitatively from non-depressive conditions, and that it can be identified as a categorical entity. In contrast, epidemiological studies support the view that depression is dynamic in nature and develops on a continuous scale. The present article reviews selected epidemiological studies of depressive subtypes. A selective review. Prior studies have found no clear differences in clinical presentation or long-term outcome between patients with melancholic and with neurotic/reactive depression. In addition, recent studies suggest that there is no clear demarcation between mild, moderate, and severe depression, pointing toward a continuity rather than categories of illness. For the individual patient, depressive symptoms seem to change over time, fulfilling criteria for major depression, minor depression, dysthymia, and subsyndromal states; the association between stressful life events and depression appears to diminish with the number of depressive episodes. Finally, recent genetic findings are congruent with a model indicating that the majority of depressions develop in the interplay between genes and stressful experiences, whereas 'reactive' depressions and 'endogenous' depressions apparently exist at a lower prevalence. Further longitudinal, analytical, and genetic epidemiologic studies are needed to reveal which conditions are mild and transient, and which may be precursors of more severe and substantial illness such as melancholia.

Quality of life in unaffected twins discordant for affective disorder

Background The disability and hardship associated with affective disorder is shared by the family members of affective patients and might affect the family member's quality of life. Method In a cross-sectional, high-risk, case–control study, monozygotic (MZ) and dizygotic (DZ) twins with (High-Risk twins) and without (the control group/Low-Risk twins) a co-twin history of affective disorder were identified through nationwide registers. The aim of the present study was to investigate the hypothesis that a genetic liability to affective disorder is associated with a lower perception of quality of life. Results Univariate analyses showed that quality of life in all domains was impaired for the 121 High-Risk twins compared to the 84 Low-Risk twins. In multiple regression analyses, the differences remained significant after adjustment for sex, age, marital status and years of education. Adjusted for the effect of subclinical anxiety and depressive symptoms, the differences were significant on the domain environment and total WHOQoL-BREF and marginally significant on the domain physical health and overall quality of life. Limitations It is not possible from the cross-sectional analyses to distinguish between subsyndromal state and trait scores. Conclusions Perceived health related quality of life might share common familial vulnerability with affective disorders. Having a co-twin with affective disorder seem to have a negative influence on quality of life of the healthy co-twin and this influence might be due to the genetic liability to affective disorder. These findings need to be replicated in future family studies.

Exposure to aircraft noise and risk of psychiatric disorders: the Elmas survey

Evidence that high levels of aircraft noise lead to psychiatric disorders in the community is contradictory. The aim of the present study was to investigate the frequency of mental disorders in a sample living in the immediate surroundings of an airport compared with those from a sample of residents from the same region who had not been exposed to the risk of aircraft noise. Exposed subjects were residents in Giliaquas in the vicinity of Elmas airport (Sardinia, Italy). The control sample was drawn from a database of a large community survey, after matching for sex, age and employment status. All subjects were interviewed using a simplified version of the Composite International Diagnostic Interview. Exposed subjects showed a higher frequency of Generalized Anxiety Disorder and Anxiety Disorder Not Otherwise Specified (NOS). Previous studies generally suggested that high levels of environmental noise are associated with subsyndromal states (psychiatric symptoms) more than with specific syndromes. The present study shows an increased risk for long-lasting syndromal anxiety states (Generalized Anxiety Disorder and Anxiety Disorder NOS), thus supporting the hypothesis of a sustained central autonomic arousal due to chronic exposure to noise.

Is there an association between subsyndromal psychotic states and neurodevelopmental markers of schizophrenia in the general population?

Is there an association between subsyndromal psychotic states and neurodevelopmental markers of schizophrenia in the general population?

Suicidal ideation in a female population sample. Relationship with depression, anxiety disorder and alcohol dependence/abuse.

The aim was to analyse the association between three psychiatric disorders (anxiety disorder, depression and alcohol dependence/abuse) and past year suicidal ideation in women. As part of the longitudinal population-based study "Women and Alcohol in Göteborg", face-to-face interviews were administered to a stratified sample of 25-65 year old women (n = 313). Past year and lifetime diagnoses of depression, anxiety disorder and alcohol dependence/abuse were made according to DSM-III-R. Past year suicidal feelings were rated according to Paykel et al. The weighted one-year prevalence of suicidal thoughts was 6.6%. Such thoughts were acknowledged by 24.2% of the women with a depressive disorder, 20% of the women with an anxiety disorder and 22.7% of those with alcohol dependence/abuse (ADA) during the past year. Depressive disorder and ADA were associated with suicidal thoughts in the univariate analysis. Such an association could not be shown for anxiety disorder. When all three disorders were entered into a logistic regression model, only depressive disorder remained associated with past year suicidal ideation. One third of the women who reported past year suicidal thoughts did not fulfil criteria for a DSM-III-R Axis I disorder during this time period. Our results underline the need for assessment of suicidality even in women with subsyndromal states.

Pharmacologic treatment of mood disorders in the elderly

There have been impressive developments in the pharmacological treatment of mood disorders in the elderly, both acute and long-term, and in the management of treatment-resistant depression. The nihilism that had prevailed previously has been replaced by cautious optimism with regard to the results of controlled trials in naturalistic settings and studies in high-risk groups, including patients with multiple medical conditions and subsyndromal states. Curr Opin Psychiatry 11:441-445.

Overanxious disorder: Subsyndromal state or specific disorder? A comparison of clinic and community samples

Examined whether overanxious disorder (OAD) is a subsyndromal state or a fpecific anxiety disorder. To date, the few studies examining this issue have used community-based rather than clinic-referred samples. In this investigation, children meeting criteria established in the Diagnostic and Statistical Manual of Mental Disorders (3rd., rev.;American Psychiatric Association, 1987) for OAD who were clinic referred were compared on several dimensions to nonreferred volunteers. There were few differences between the two OAD samples, and when differences did occur, they represented ancillary rather than primary aspects of the disorder. These results support previous research suggesting that, as currently defined, OAD represents a subsyndromal state. The results are discussed in terms of the current diagnostic criteria and changes that may make the diagnosis of OAD more meaningful.