Substance Disorders Research Articles

Neural Circuitry of Impaired Emotion Regulation in Substance Use Disorders.

Impaired emotion regulation contributes to the development and severity of substance use disorders (substance disorders). This review summarizes the literature on alterations in emotion regulation neural circuitry in substance disorders, particularly in relation to disorders of negative affect (without substance disorder), and it presents promising areas of future research. Emotion regulation paradigms during functional magnetic resonance imaging are conceptualized into four dimensions: affect intensity and reactivity, affective modulation, cognitive modulation, and behavioral control. The neural circuitry associated with impaired emotion regulation is compared in individuals with and without substance disorders, with a focus on amygdala, insula, and prefrontal cortex activation and their functional and structural connectivity. Hypoactivation of the rostral anterior cingulate cortex/ventromedial prefrontal cortex (rACC/vmPFC) is the most consistent finding across studies, dimensions, and clinical populations (individuals with and without substance disorders). The same pattern is evident for regions in the cognitive control network (anterior cingulate and dorsal and ventrolateral prefrontal cortices) during cognitive modulation and behavioral control. These congruent findings are possibly related to attenuated functional and/or structural connectivity between the amygdala and insula and between the rACC/vmPFC and cognitive control network. Although increased amygdala and insula activation is associated with impaired emotion regulation in individuals without substance disorders, it is not consistently observed in substance disorders. Emotion regulation disturbances in substance disorders may therefore stem from impairments in prefrontal functioning, rather than excessive reactivity to emotional stimuli. Treatments for emotion regulation in individuals without substance disorders that normalize prefrontal functioning may offer greater efficacy for substance disorders than treatments that dampen reactivity.

An Implementation and Process Evaluation of the Louisiana 22nd Judicial District’s Behavioral Health Court

The national offender reentry movement, Second Chance Act, and the widespread transfer of offender programming to community corrections have coalesced to substantially increase treatment for mental health and substance disorders within the criminal justice system. Intervention commonly entails program evaluation for accountability and empirical evidence by which to specify what works. Though mixed methods evaluation is preferable to a singular qualitative or quantitative approach, process steps are commonly overlooked. This paper relates an implementation and process design and evaluation midpoint findings for the Louisiana 22nd Judicial District’s Behavioral Health Court program, a post-conviction treatment initiative for mental health offenders. Interview guides and a fidelity instrument facilitated site visit data collection. Findings inform program implementation intensity, performance, improvement opportunities, and related fidelity research.

Infectious, atopic and inflammatory diseases, childhood adversities and familial aggregation are independently associated with the risk for mental disorders: Results from a large Swiss epidemiological study.

AIMTo examine the associations between mental disorders and infectious, atopic, inflammatory diseases while adjusting for other risk factors.METHODSWe used data from PsyCoLaus, a large Swiss Population Cohort Study (n = 3720; age range 35-66). Lifetime diagnoses of mental disorders were grouped into the following categories: Neurodevelopmental, anxiety (early and late onset), mood and substance disorders. They were regressed on infectious, atopic and other inflammatory diseases adjusting for sex, educational level, familial aggregation, childhood adversities and traumatic experiences in childhood. A multivariate logistic regression was applied to each group of disorders. In a complementary analysis interactions with sex were introduced via nested effects.RESULTSAssociations with infectious, atopic and other chronic inflammatory diseases were observable together with consistent effects of childhood adversities and familial aggregation, and less consistent effects of trauma in each group of mental disorders. Streptococcal infections were associated with neurodevelopmental disorders (men), and measles/mumps/rubella-infections with early and late anxiety disorders (women). Gastric inflammatory diseases took effect in mood disorders (both sexes) and in early disorders (men). Similarly, irritable bowel syndrome was prominent in a sex-specific way in mood disorders in women, and, moreover, was associated with early and late anxiety disorders. Atopic diseases were associated with late anxiety disorders. Acne (associations with mood disorders in men) and psoriasis (associations with early anxiety disorders in men and mood disorders in women) contributed sex-specific results. Urinary tract infections were associated with mood disorders and, in addition, in a sex-specific way with late anxiety disorders (men), and neurodevelopmental and early anxiety disorders (women).CONCLUSIONInfectious, atopic and inflammatory diseases are important risk factors for all groups of mental disorders. The sexual dimorphism of the associations is pronounced.

Maternal Psychosocial and Environmental Factors Associated With Infant Impaired Development in Sao Paulo, Brazil: A Population-Based Birth Cohort Study

Background: Early life experiences have important consequences on health and human capital throughout life. The development is the result of interaction between the child's biological characteristics and cultural and social factors on which it is inserted. Biological factors that cause developmental delay associated with environmental factors increase the chance of the infant having an inappropriate development. This shows the importance of studies assessing factors related to child development. Objective: The aim was to characterize the neurological development of children 6-8 months ago through the Bayley scale in a population-based sample, then estimate the prevalence of delay and identifying psychosocial and environmental risk factors. Method: A longitudinal epidemiological study of birth cohort study in a group of 368 infants and their mothers. Two moments of assessment were considered: a) at the beginning of the third trimester of gestation and b) when the infants were 6-8 months of age. The study aims to examine the neurological development of the children considered for the study through the Bayley scale, to estimate the prevalence of delay in a population-based sample and, finally, to identifying maternal psychosocial and environmental risk factors. Results: Indicated that maternal stress factors (i.e. anxiety and substance disorder during pregnancy, lower maternal schooling and economic class) were associated with lower cognitive development in infants. Conclusion: This study shows the importance of screening to identify possible developmental delays, for subsequent intervention programs to prevent or minimize future hazards and allow the child to develop to their full potential.

Disability-adjusted Life Years (DALYs) for Mental and Substance Use Disorders in the Korean Burden of Disease Study 2012.

The purpose of this study was to estimate the national burden of mental substance disorders on medical care utilization in Korea using National Health Insurance System (NHIS) data and updated disability weight, in terms of disability-adjusted life years (DALYs). For each of the 24 disorders, the incident years lived with disability (YLDs) was calculated, using NHIS data to estimate prevalence and incidence rates. The DisMod-II software program was used to model duration and remission. The years of life lost (YLLs) due to premature death were calculated from causes of death statistics. DALYs were computed as the sum of YLDs and YLLs, and time discounting and age weighting were applied. The year examined was 2012, and the subjects were divided into 9 groups according to age. In 2012, the Korean burden of mental and substance use disorders was 945,391 DALYs. More than 98% of DALYs were from YLDs, and the burden in females was greater than that in males, though the burden in males aged less than 19 years old was greater than that in females. Unipolar depressive disorders, schizophrenia, and anxiety disorders were found to be major diseases that accounted for more than 70% of the burden, and most DALYs occurred in their 30–59. Mental and substance use disorders accounted for 6.2% of the total burden of disease and were found to be the 7th greatest burden of disease. Therefore, mental and substance use disorders need to be embraced by mainstream health care with resources commensurate with the burden.

Mouse Social Interaction Test (MoST): a quantitative computer automated analysis of behavior.

Rodents are the most commonly used preclinical model of human disease assessing the mechanism(s) involved as well as the role of genetics, epigenetics, and pharmacotherapy on this disease as well as identifying vulnerability factors and risk assessment for disease critical in the development of improved treatment strategies. Unfortunately, the majority of rodent preclinical studies utilize single housed approaches where animals are either entirely housed and tested in solitary environments or group housed but tested in solitary environments. This approach, however, ignores the important contribution of social interaction and social behavior. Social interaction in rodents is found to be a major criterion for the ethological validity of rodent species-specific behavioral characteristics (Zurn et al. 2007; Analysis 2011). It is also well established that there is significant and growing number of reports, which illustrates the important role of social environment and social interaction in all diseases, with particularly significance in all neuropsychiatric diseases. Thus, it is imperative that research studies be able to add large-scale evaluations of social interaction and behavior in mice and benefit from automated tracking of behaviors and measurements by removing user bias and by quantifying aspects of behaviors that cannot be assessed by a human observer. Single mouse setups have been used routinely, but cannot be easily extended to multiple-animal studies where social behavior is key, e.g., autism, depression, anxiety, substance and non-substance addictive disorders, aggression, sexual behavior, or parenting. While recent efforts are focusing on multiple-animal tracking alone, a significant limitation remains the lack of insightful measures of social interactions. We present a novel, non-invasive single camera-based automated tracking method described as Mouse Social Test (MoST) and set of measures designed for estimating the interactions of multiple mice at the same time in the same environment interacting freely. Our results show measurement of social interactions and designed to be adaptable and applicable to most existing home cage systems used in research, and provide a greater level of detailed analysis of social behavior than previously possible. The present study describes social behaviors assessed in a home cage environment setup containing six mice that interact freely over long periods of time, and we illustrate how these measures can be interpreted and combined to classify rodent social behaviors. In addition, we illustrate how these measures can be interpreted and combined to classify and analyze comprehensively rodent behaviors involved in several neuropsychiatric diseases as well as provide opportunity for the basic research of rodent behavior previously not possible.

The effect of race/ethnicity on the relation between substance use disorder diagnosis and substance use treatment receipt among male serious adolescent offenders

The high rates of substance disorders in the juvenile justice system, as well as the relation between substance use and reoffending, suggest the importance of substance use treatment service and understanding the factors that influence treatment provision. The current study tested whether race/ethnicity affects the relation between substance use disorder diagnosis and the receipt of substance use treatment services among a sample of male serious juvenile offenders (N=638). Findings showed that among adolescents with a substance use disorder diagnosis, there were no race/ethnicity differences in substance use treatment receipt. However, among adolescents without a substance use disorder diagnosis, non-Hispanic Caucasians were more likely to receive substance use treatment than were Hispanics or African-Americans. Additionally, findings showed that there were race/ethnicity differences in service receipt at moderate levels of substance use problems, such that non-Hispanic Caucasians were more likely to receive substance use treatment than Hispanics or African-Americans. There were no race/ethnicity differences in treatment receipt when substance use problems were either very severe or very low. Results suggest that race/ethnicity may play a role in service provision in the juvenile justice system when levels of need are less clear.

Mental health outcomes in times of economic recession: a systematic literature review.

BackgroundCountries in recession experience high unemployment rates and a decline in living conditions, which, it has been suggested, negatively influences their populations’ health. The present review examines the recent evidence of the possible association between economic recessions and mental health outcomes.MethodsLiterature review of records identified through Medline, PsycINFO, SciELO, and EBSCO Host. Only original research papers, published between 2004 and 2014, peer-reviewed, non-qualitative research, and reporting on associations between economic factors and proxies of mental health were considered.ResultsOne-hundred-one papers met the inclusion criteria. The evidence was consistent that economic recessions and mediators such as unemployment, income decline, and unmanageable debts are significantly associated with poor mental wellbeing, increased rates of common mental disorders, substance-related disorders, and suicidal behaviours.ConclusionOn the basis of a thorough analysis of the selected investigations, we conclude that periods of economic recession are possibly associated with a higher prevalence of mental health problems, including common mental disorders, substance disorders, and ultimately suicidal behaviour. Most of the research is based on cross-sectional studies, which seriously limits causality inferences. Conclusions are summarised, taking into account international policy recommendations concerning the cost-effective measures that can possibly reduce the occurrence of negative mental health outcomes in populations during periods of economic recession.

Substance Use and Cumulative Exposure to American Society: Findings From Both Sides of the US-Mexico Border Region.

We investigated whether Mexican immigration to the United States exerts transnational effects on substance use in Mexico and the United States. We performed a cross-sectional survey of 2336 Mexican Americans and 2460 Mexicans in 3 Texas border metropolitan areas and their sister cities in Mexico (the US-Mexico Study on Alcohol and Related Conditions, 2011-2013). We collected prevalence and risk factors for alcohol and drug use; Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, alcohol-use disorders; and 2 symptoms (hazardous use and quit or control) of drug use disorder across a continuum of migration experiences in the Mexican and Mexican American populations. Compared with Mexicans with no migrant experience, the adjusted odds ratios for this continuum of migration experiences ranged from 1.10 to 8.85 for 12-month drug use, 1.09 to 5.07 for 12-month alcohol use disorder, and 1.13 to 9.95 for 12-month drug-use disorder. Odds ratios increased with longer exposure to US society. These findings are consistent with those of 3 previous studies. People of Mexican origin have increased prevalence of substance use and disorders with cumulative exposure to US society.

Trends in diagnosis of bipolar disorder: Have the boundaries changed?

There are concerns that the diagnostic boundaries of bipolar disorder have expanded. This study seeks evidence of change in diagnostic practice at three boundaries: the 'lower' boundary with subclinical mood conditions, the 'lateral' boundary with other mental health conditions (psychotic, anxiety, substance and personality disorders) and the 'internal' boundary within affective disorders. Diagnoses recorded in health system administrative data collections were used as a measure of clinician diagnostic behaviour. We examined all diagnoses made by public (state operated) inpatient and community mental health services in New South Wales, Australia, from 2003 to 2014. A total of 31,746 people had at least one recorded diagnosis of bipolar disorder in the period. There was a significant upward trend in the age-standardised population rate of diagnosis of bipolar disorder. Bipolar disorders made up an increasing proportion of psychosis diagnoses. There was no increase in the rate of comorbid diagnosis of bipolar disorders with non-psychotic disorders or in the likelihood of diagnosis of bipolar disorder at first or subsequent episodes of depression. There were significant reductions in diagnoses of schizophrenia, particularly in younger people. There may be some increase in diagnoses of bipolar disorder in New South Wales public mental health services. However, some changes in diagnosis, particularly in younger adults, may reflect movement away from diagnoses of schizophrenia towards a range of other diagnoses, rather than specific movement towards bipolar disorder. Expansion of bipolar disorder may have been more marked in private practice settings and may have involved the poorly defined bipolar II subtype.

The mental health of US Black women: the roles of social context and severe intimate partner violence

ObjectiveBlack women continue to have rates of mental health conditions that can be negative for their well-being. This study examined the contribution of social and contextual factors and severe physical...

Mental Health Treatment Among Soldiers With Current Mental Disorders in the Army Study to Assess Risk and Resilience in Service Members (Army STARRS).

A representative sample of 5,428 nondeployed Regular Army soldiers completed a self-administered questionnaire (SAQ) and consented to linking SAQ data with administrative records as part of the Army Study to Assess Risk and Resilience in Service members. The SAQ included information about prevalence and treatment of mental disorders among respondents with current Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) internalizing (anxiety, mood) and externalizing (disruptive behavior, substance) disorders. 21.3% of soldiers with any current disorder reported current treatment. Seven significant predictors of being in treatment were identified. Four of these 7 were indicators of psychopathology (bipolar disorder, panic disorder, post-traumatic stress disorder, 8+ months duration of disorder). Two were sociodemographics (history of marriage, not being non-Hispanic Black). The final predictor was history of deployment. Treatment rates varied between 4.7 and 71.5% depending on how many positive predictors the soldier had. The vast majority of soldiers had a low number of these predictors. These results document that most nondeployed soldiers with mental disorders are not in treatment and that untreated soldiers are not concentrated in a particular segment of the population that might be targeted for special outreach efforts. Analysis of modifiable barriers to treatment is needed to help strengthen outreach efforts.

Patient Perceptions of Prejudice and Discrimination by Health Care Providers and its Relationship with Mental Disorders: Results from the 2012 Canadian Community Health-Mental Health Survey Data.

Using data from a nationally representative survey, the Canadian Community Health Survey-Mental Health, this secondary analysis aimed to determine the prevalence of perceived prejudice by health care providers (HCPs) and its relationship with mental disorders. Respondents accessing HCPs in the prior year were asked if they experienced HCP prejudice. A hypothesis driven multivariable logistic regression analysis was conducted to determine the relationship between type of mental disorders and HCP prejudice. Among the 3006 respondents, 10.9% perceived HCP prejudice, 62.4% of whom reported a mental disorder. The adjusted odds of prejudice was highest for respondents with anxiety (OR 3.12; 95% CI 1.60, 6.07), concurrent mood or anxiety and substance disorders (OR 3.08; 95% CI 1.59, 5.95) and co-occurring mood and anxiety disorders (OR 2.89; 95% CI 1.68, 4.97) compared to respondents without any mental disorders. These findings are timely for informing discussions regarding policies to address HCP prejudice towards people with mental disorders.

Childhood adversity profiles and adult psychopathology in a representative Northern Ireland study

Childhood adversities are key aetiological factors in the onset and persistence of psychopathology. The aims of this study were to identify childhood adversity profiles, and investigate the relationship between the adversity classes and psychopathology in Northern Ireland. The study utilized data from the Northern Ireland Study of Health and Stress, an epidemiological survey (N=1986), which used the CIDI to examine mental health disorders and associated risk factors. Latent Class Analysis revealed 3 distinct typologies; a low risk class (n=1709; 86%), a poly-adversity class (n=122; 6.1%), and an economic adversity class (n=155; 7.8%). Logistic Regression models revealed that individuals in the economic adversity class had a heightened risk of anxiety and substance disorders, with individuals in the poly-adversity class more likely to have a range of mental health problems and suicidality. The findings indicate the importance of considering the impact of co-occurring childhood adversities when planning treatment, prevention, and intervention programmes.

Preschoolers' Psychopathology and Temperament Predict Mothers' Later Mood Disorders.

Considerable research exists documenting the relationship between maternal mood disorders, primarily major depressive disorder (MDD), and a variety of negative child outcomes. By contrast, research exploring the reverse pathway whereby child traits are associated with later maternal mood disorders is much more limited. We examined whether young children's temperament and psychopathology predicted maternal mood disorders approximately 6 years later. Child temperament and symptoms were assessed at age three using semi-structured diagnostic interviews and parent-report inventories. Maternal psychopathology was assessed with semi-structured interviews when children were 3 and 9 years old. Mothers also reported on their marital satisfaction when children were 3 and 6 years old. Child temperamental negative affectivity (NA), depressive symptoms, and externalizing behavior problems significantly predicted maternal mood disorders over and above prior maternal mood, anxiety, and substance disorders. The link between children's early externalizing symptoms and maternal mood disorders 6 years later was mediated by maternal marital satisfaction 3 years after the initial assessment. These findings suggest that early child temperament and psychopathology contribute to risk for later maternal mood disorders both directly and through their impact on the marital system. Research indicates that effective treatment of maternal depression is associated with positive outcomes for children; however, this study suggests that treating early child problems may mitigate the risk of later maternal psychopathology.

The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) Waves 1 and 2: review and summary of findings.

The NESARC, a "third-generation" psychiatric epidemiologic survey that integrated detailed measures of alcohol and drug use and problems has been the data source for over >850 publications. A comprehensive review of NESARC findings and their implications is lacking. NESARC was a survey of 43,093 participants that covered alcohol, drug and psychiatric disorders, risk factors, and consequences. Wave 1 of the NESARC was conducted in 2001-2002. Three years later, Wave 2 follow-up re-interviews were conducted with 34,653 of the original participants. Scopus and Pubmed were used to search for NESARC papers, which were sorted into topic areas and summarized. The most common disorders were alcohol and posttraumatic stress disorders, and major depression. Females had more internalizing disorders and males had more externalizing disorders, although the preponderance of males with alcohol disorders (the "gender gap") was less pronounced than it was in previous decades. A race/ethnic "paradox" (lower risk among disadvantaged minorities than whites) remains unexplained. Younger participants had higher risk for substance and personality disorders, but not unipolar depressive or anxiety disorders. Psychiatric comorbidity was extensive and often formed latent trans-diagnostic domains. Since 1991-1992, risk for marijuana and prescription drug disorders increased, while smoking decreased, although smoking decreases were less pronounced among those with comorbidity. A nexus of comorbidity, social support, and stress predicted transitions in diagnostic status between Waves 1 and 2. Childhood maltreatment predicted psychopathology. Alcohol and drug use disorders were seldom treated; attitudinal barriers (little perceived need, perceived alcoholism stigma, pessimism about efficacy) were more important in predicting non-treatment than financial barriers. Understanding comorbidity and the effects of early stressors will require research incorporating biologic components, e.g., genetic variants and brain imaging. The lack of treatment for alcohol and drug disorders, predicted by attitudinal rather than financial variables, suggests an urgent need for public and professional education to reduce the stigma associated with these disorders and increase knowledge of treatment options.

Predictors of rapid reincarceration in mentally ill young offenders.

Describe characteristics of mentally ill young offenders released from custody and predictors of those who rapidly returned to custody. Ambidirectional cohort study of 51 young males with mental disorders released from the largest New South Wales Juvenile Justice Centre (2005-2007), a health file audit at time of release and prospective determination of reincarceration. Overall 47% were Aboriginal, 43% originated from regional communities, substance disorders were highly prevalent and only 12% accessed prior community mental health care. Over half (57%) satisfied diagnostic criteria for schizophrenia spectrum disorder. In custody, 39% were suicidal and 18% were homicidal. A majority (90%) returned to custody over a median of 28 months; half within five months of release. Schizophrenia/schizophreniform disorder (p<.001), bipolar disorder (p=.001) and schizoaffective disorder (p=.005) predicted rapid reincarceration, with shorter community survival than those without those diagnoses (p=.009). Antipsychotic treatment (p=.006) and treatment duration in custody (p=.006) predicted longer community survival. Aboriginality, younger age, prior incarceration and substance disorders were not predictive of rapid reincarceration. Serious mental illness was a significant predictor of rapid reincarceration in young offenders. Treatment improved community survival. The findings highlight the need for optimal psychiatric treatment and post-release care for young offenders with mental illness.

Non-suicidal self-injury with and without borderline personality disorder: Differences in self-injury and diagnostic comorbidity

Although non-suicidal self-injury (NSSI) occurs in people with and without borderline personality disorder (BPD), few studies have compared the clinical characteristics of these two groups. The present study sampled adults with a history of NSSI and compared those with and without BPD on (a) NSSI features, (b) co-occurring psychiatric disorders, and (c) severity of depression, suicidal ideation and emotion dysregulation. Participants (NSSI+BPD, n=46; NSSI Only, n=54) completed semi-structured interviews and self-report measures. Whereas the groups did not differ in age of NSSI onset, the NSSI+BPD group engaged in more frequent, recent and severe NSSI, and reported higher rates of skin carving, head banging, self-punching and self-scratching than the NSSI Only group. Participants with BPD also showed greater diagnostic comorbidity, particularly for anxiety disorders, but did not differ from participants without BPD in rates of mood, substance or psychotic disorders. The NSSI+BPD group reported more severe depressive symptomatology, suicidal ideation and emotion dysregulation than the NSSI Only group. Supplementary analyses on the subset of participants with recent (past year) NSSI revealed similarly medium to large differences between those with and without BPD. Implications for assessment and treatment are discussed.

Lifetime and 12-month prevalence, severity and unmet need for treatment of common mental disorders in Japan: results from the final dataset of World Mental Health Japan Survey.

The aim of this study is to estimate the lifetime and 12-month prevalence, severity and treatment of Diagnostic and Statistical Manual of Mental Disorders fourth edition (DSM-IV) mental disorders in Japan based on the final data set of the World Mental Health Japan Survey conducted in 2002-2006. Face-to-face household interviews of 4130 respondents who were randomly selected from Japanese-speaking residents aged 20 years or older were conducted from 2002 to 2006 in 11 community populations in Japan (overall response rate, 56%). The World Mental Health version of the World Health Organization Composite International Diagnostic Interview (WMH-CIDI), a fully structured, lay administered psychiatric diagnostic interview, was used for diagnostic assessment. Lifetime/12-month prevalence of any DSM-IV common mental disorders in Japan was estimated to be 20.3/7.6%. Rank-order of four classes of mental disorders was anxiety disorders (8.1/4.9%), substance disorders (7.4/1.0%), mood disorders (6.5/2.3%) and impulse control disorders (2.0/0.7%). The most common individual disorders were alcohol abuse/dependence (7.3/0.9%), major depressive disorder (6.1/2.2%), specific phobia (3.4/2.3%) and generalized anxiety disorder (2.6/1.3%). While the lifetime prevalence of any mental disorder was greater for males and the middle-aged, the persistence (proportion of 12-month cases among lifetime cases) of any mental disorder was greater for females and younger respondents. Among those with any 12-month disorder, 15.3% were classified as severe, 44.1% moderate and 40.6% mild. Although a strong association between severity and service use was found, only 21.9% of respondents with any 12-month disorder sought treatment within the last 12 months; only 37.0% of severe cases received medical care. The mental health specialty sector was the most common resource used in Japan. Although the prevalence of mental disorders were quite low, mental disorders were the second most prevalent cause of severe role impairment among chronic physical and mental disorders. These results suggest lower prevalence of mental disorders in Japan than that in Western countries, although the general pattern of disorders, risk factors and unmet need for treatment were similar to those in other countries. Greater lifetime prevalence for males and greater persistence for females seems a unique feature of Japan, suggesting a cultural difference in gender-related etiology and course of disorders. The treatment rate in Japan was lower than that in most other high-income countries in WMH surveys.

Current Treatments for Delusional Disorder

Delusional disorders form part of the spectrum of psychotic disorders in psychiatry. They are poorly understood in practically every aspect of their nature, including cause, phenomenology, prevalence, comorbidity, course, treatment, and prognosis. The key symptom in delusional disorders is one or more delusions. A cardinal characteristic of delusional disorder, conviction that one is not mentally ill, contributes complexity to the treatment challenges and profoundly affects the therapeutic relationship. Diagnosis and differential diagnosis are critical tasks. Delusional conditions may arise from many sources and, only when the case conforms to the criteria and is clearly idiopathic—is a primary delusional disorder—can we feel confident that the patient suffers from delusional disorder rather than a secondary delusional condition. Adequate treatment follows principles for the treatment of delusions. First line pharmacological treatment for delusional disorder is antipsychotic medication, both first and second-generation agents, and some evidence suggests that clozapine may be effective in certain cases. The assumption in such a formulation is that the delusion(s) encountered in delusional disorders respond as a class of symptoms found in different disorders. Hence, the approach for failed interventions with these agents may be similar to that proposed for the treatment of schizophrenia or other psychotic disorders. Namely, searching for evidence of failure to take medication, inadequate dosing, a missed diagnosis of a substance disorder, medical condition, or even another psychiatric disorder should be considered. For individuals with delusional disorders who are also experiencing comorbid depression or anxiety, the addition of appropriate agents for those symptoms may provide a synergistic strategy for overall effectiveness. Psychotherapy is another important clinical tool. Cognitive behavioral therapy focusing on different aspects of delusions (i.e., anxiety, reasoning biases, faulty logic, etc.) has demonstrated some value for at least short-term improvement. Various techniques may be useful in allying with the patient and supplying means to assist in managing their thinking and approach to circumstances and factors that promote delusion formation and encourage actions taken to respond. A significant problem in applying what we know about delusional disorders to treatment is the limited available evidence. Lack of randomized controlled trials, which form the standard in most clinical disorders, is a major shortcoming. Recent observations of compromised cognitive functioning in working memory, attention, and executive function should be replicated with similar standards. Systematic case studies and large series are useful, and a growing effort to be more rigorous methodologically in all contributions including case registries and longer follow-up studies is promising. Nevertheless, our knowledge remains less than optimal. These comments apply not only to pharmacological observations but also to those of neuropsychological and psychotherapeutic studies.