December 1997, Volume 42, Number 10
Behaviour Therapy for ObsessiveCompulsive
Disorder: A Decade of Progress
Isaac Marks
Objective:
To review the last decade of behaviour therapy research in obsessivecompulsive disorder
(OCD).
Method:
The most salient research was analyzed.
Results:
Many studies confirmed that exposure and ritual prevention (ERP) effectively reduced
compulsive rituals and obsessive thoughts in most patients in all age groups, although a minority
of the patients did not complete treatment. Gains persisted to follow-up 2 to 6 years later in
several countries. Improvement after ERP generalized to obsessivecompulsive beliefs, mood,
work, and social adjustment, and was accompanied by reduction in cerebral blood flow in the
right caudate nucleus. Teaching patients how to prevent relapse seems to reduce the risk of
recurrence. ERP yields slightly more improvement than does appropriate antidepressant
medication and is followed by far less relapse after treatment has stopped, so ERP may be more
cost-effective in the long term. Antidepressant medication is a useful adjunct to ERP when OCD
is accompanied by comorbid depression. The therapist now tends to teach patients how to carry
out self-exposure and self-imposed ritual prevention, rather than to impose ERP on them.
Self-help manuals help patients to do this, and computer aids to allow patients to learn how to do
ERP at home have been valuable in pilot studies. Cognitive therapy without ERP was as useful
as ERP.
Conclusion:
ERP is of lasting value for OCD. Long-term cost-effectiveness comparisons are needed of
self-administered ERP versus cognitive therapy and versus medication. Studies are also needed
of brief psychological treatment for depression comorbid with OCD.
(Can J Psychiatry 1997;42:10211027)
Efficacy and Tolerability of Moclobemide in
Comparison with Placebo, Tricyclic Antidepressants,
and Selective Serotonin Reuptake Inhibitors in Elderly
Depressed Patients: A Clinical Overview
Roman Amrein, MD, Max Stabl, MD, Stephan Henauer, MD, Eva Affolter, Iris Jonkanski
Objective:
To review the efficacy and safety of moclobemide in comparison with TCAs (for our purposes,
"TCAs" will represent tricyclic and tetracyclic antidepressants, including maprotilin and
mianserin) and selective serotonin reuptake inhibitors (SSRIs) in elderly depressed patients.
Methods:
The efficacy data reviewed were obtained from the following sources: 1) results of published
studies in the elderly; 2) data on patients aged 60 years extracted from all available controlled
trials in adults ( 18 years) in which moclobemide was compared with TCAs or SSRIs; and 3) the
adverse events were extracted for patients aged 60 years from the safety data base of all
available comparative short-term studies with moclobemide versus TCAs, SSRIs, or placebo and
of long-term studies with moclobemide.
Results:
The data show that moclobemide is an effective antidepressant in depressed patients aged 60
years. The response rate to moclobemide was 50% to 55% in this population. Moclobemide was
more effective than placebo and was of similar efficacy to the TCAs and the more recently
introduced SSRIs. The tolerability of moclobemide was rated as "very good" or "good" in almost
90% of these patients, which was better than the tolerability of TCAs and similar to that of
SSRIs. Patients without any adverse events were more frequently found in the moclobemide
group than in those treated with TCAs (P < 0.01) or SSRIs (P < 0.01). Adverse events of the
anticholinergic type were more frequent with TCAs than with moclobemide (P < 0.001), and
nausea was found 3 times more frequently with SSRIs than with moclobemide (P < 0.01).
Conclusions:
Moclobemide is an effective and well-tolerated antidepressant for the treatment of elderly
depressed patients.
(Can J Psychiatry 1997;42:10431050)
Risk Assessments for Acute Violence to Third Parties:
A Review of the Literature
Lorraine E Ferris, PhD, C Psych, Jane Sandercock, BSc, OT, Brian Hoffman, MD, FRCPC,
Marvin Silverman, MD, FRCPC, Harvey Barkun, OC, MD, FRCPC, John Carlisle, MD, LLB,
FCLM, Cheryl Katz, LLB
Objectives:
To provide an overview of risk assessments for acute violence to third parties by combining a
clinical and research focus and to offer guidelines to physicians conducting clinical assessments.
Method:
A computerized literature search of the MEDLINE and PSYCHINFO data bases from 1967 to
1996 was completed using the key words violence, aggression, dangerous behaviour, risk, risk
assessment, risk factors, and practice guidelines. The search yielded 116 relevant references, 26
of which were original research articles on risk factor identification. A secondary search, based
on the citations from the primary search, yielded an additional 8 general discussion articles.
Results:
Risk assessments may be conducted using different methods, although all methods should be
systematic and comprehensive. Research shows that risk assessments do have validity for use in
short-term prediction and that it is possible to develop clinical guidelines in this area. A
combined clinical and research approach holds the most promise for improving the accuracy of
probability estimates, and most published guides and tools rely on such a combination.
Conclusions:
Risk assessments are an important and necessary part of the clinical examination. Because this
field has sufficiently evolved, there is abundant literature to refer to when determining what
constitutes an acceptable assessment for risk of violence to third parties and when it is
appropriate to conduct such an examination.
(Can J Psychiatry 1997;42:10511060)
Breast-Feeding and Postpartum Depression: Is There
a Relationship?
Shaila Misri, MD, FRCPC, Dana A Sinclair, PhD, Annie J Kuan, BA
Objective:
To study the relationship between breast-feeding cessation and the onset of postpartum
depression.
Method:
The association between breast-feeding and depression was retrospectively examined in an
obstetrical outpatient sample of 51 postpartum women who were suffering from major
depression and who had stopped breast-feeding. Self-report questionnaire data were obtained
from the subjects; the severity of the illness and the clinical course of each subject were
evaluated.
Results:
The majority (39 out of 51; 83%) of the women reported that their depression began before the
cessation of breast-feeding, while only 8 patients (17%) stated that their depression was
subsequent to breast-feeding cessation.
Conclusions:
In an outpatient sample of depressed postpartum women, the onset of depression preceded the
cessation of breast-feeding. The severity of the illness did not appear to influence breast-feeding
persistence significantly.
(Can J Psychiatry 1997;42:10611065)
Neurocognitive Correlates of Positive and Negative
Syndromes in Schizophrenia
LNP Voruganti, MD, RJ Heslegrave, PhD, AG Awad, MD, PhD
Objective:
To identify the neurocognitive correlates of positive and negative schizophrenic syndromes
using a battery of information-processing measures as the principal method of evaluation.
Method:
Fifty-two treated, symptomatically stable, schizophrenic (DSM-III-R) patients and 24
age-matched, healthy volunteers were administered a computerized cognitive test battery
(COGLAB). The battery included measures of preattentional, attentional, conceptual, and
psychomotor performance. The patients' psychopathology was rated with the positive and
negative syndromes scale (PANSS), which derived scores for positive symptoms, negative
symptoms, general psychopathology, and insight.
Results:
Compared with controls, schizophrenic patients, as a group, showed significant deficits on all of
the neurocognitive tasks. Impaired performance on the backward masking, span of apprehension,
and Wisconsin card sorting tasks correlated significantly with negative symptoms (r =
0.270.40), general psychopathology (r = 0.290.42 ) and impaired insight (r = 0.340.52), but
no clear association was found between positive symptom scores and neurocognitive deficits.
Conclusions:
Schizophrenic patients with predominantly negative symptoms and impaired insight seem to
exhibit more severe neurocognitive deficits, which lends support to the evolving concept of
schizophrenia subtypes and their distinctive neurobiological mechanisms.
(Can J Psychiatry 1997;42:10661071)
Suicide Attempts Among Turkish Psychiatric Patients
B Coar, MD, N Koçal, MD, Z Arikan, MD, E Iik, MD
Objectives:
The aim of this study was to investigate the sociodemographic characteristics of those who
attempt suicide in an Islamic country, the effect of religion on suicide attempts, and the
frequency of DSM-III-R diagnoses in suicide attempters referred to the Gazi Medical School
Psychiatry Department.
Method:
Medical records of 185 cases of suicide attempts were reviewed.
Results:
There was a predominance of single, female subjects. Students, housewives, and employees
represented the 3 largest groups. Drug overdose was the most common method of suicide
attempt, and the most common DSM-III-R diagnosis was depression. The rate of repetition of
suicide attempt was 43.3%.
Conclusion:
Suicide is one of the major problems among Turkish psychiatric patients, although the Islamic
religion strongly disapproves of it.
(Can J Psychiatry 1997;42:10721075)