A pilot sequential study of cognitive therapy and pharmacotherapy of atypical depression.

BACKGROUND: Parallel comparison studies of cognitive therapy and antidepressant medication have suggested that both treatments are effective. However, we cannot determine from these studies whether cognitive therapy and antidepressant medication are effective for the same populations of depressives. A sequential study in which nonresponders to the first treatment are then treated with the second can address this issue. METHOD: Twenty-seven patients meeting DSM-III criteria for major depression or dysthymic disorder and Columbia criteria for atypical depression received cognitive therapy followed by antidepressant medication for cognitive therapy nonresponders. A response rate with the second treatment equal to that expected with placebo would suggest both treatments target the same depressive population. RESULTS: Of the 25 completers of the study, 14 (56%) were judged responders to cognitive therapy alone. Sixty-nine percent (9/13) of the responders maintained their benefits for 6 months or more. Seven of the 11 cognitive therapy nonresponders (63%) responded to antidepressant medication. These results were compared with those of a concurrent double-blind medication study; both its sample and ours were drawn from the same population at the same time: cognitive therapy and antidepressant medication response rates were higher than expected with placebo (28%). CONCLUSION: The results suggest that (1) cognitive therapy and antidepressant medication are effective treatments for differing populations of depressed patients, as the antidepressant medication response of cognitive therapy nonresponders was greater than expected with placebo, and (2) cognitive therapy has a lasting effect.     

Effect of 6-hydroxydopamine lesions of the amygdala on intravenous cocaine self-administration under a progressive ratio schedule of reinforcement

Bilateral six-hydroxydopamine (6-OHDA) lesions were placed in the amygdala of rats self-administering cocaine (1.5 mg/kg per injection i.v.) under a progressive ratio schedule of reinforcement. Post-lesion access to three doses of cocaine (1.5, 0.75 and 0.37 mg/kg per injection i.v.) revealed a lesion effect only at the highest dose. At this dose, the lesion caused a significant increase in breaking point. No change in the breaking point was produced at the lower two doses. The biochemical results show a significant reduction in dopamine and DOPAC levels within the amygdala and an increase in dopamine within the NACC. In contrast, noradrenaline and serotonin (5-HT) levels were unaffected by the lesion in any of the dissected areas. These results demonstrate that no specific effect on cocaine reinforcement was produced by 6-OHDA lesions of the amygdala. The possibility that the lesion may have attenuated the anxiogenic qualities of the high dose of cocaine is discussed.     

Precursors of schizophrenia

Several likely precursors of schizophrenia have been identified. These range from possibly causative features, such as exposure to perinatal insults, to features that are the effects of an underlying vulnerability, such as abnormal childhood behaviors. Unfortunately none of these precursors is specific enough to be used in identifying individuals for targeted preventive treatment. A more useful strategy is to combine risk factors for psychotic disorders in a population seeking help for psychiatric problems. Thus, individuals who are possibly prodromal are identified. Research into this group has found high rates of onset of psychotic disorders, particularly schizophrenia, within a short time frame. Preliminary treatment trials suggest that symptoms can be reduced and psychosis onset possibly delayed or averted.     

Cardiac operations in patients with hematologic malignancies.

OBJECTIVES: Patients with hematologic malignancies are frequently in need of major cardiac operations. Previous reports suggest an increased risk for perioperative complications in these immunodeficient patients. METHODS: Patients diagnosed with any type of hematologic malignancy who underwent open-heart surgery at our institution between 7/1996 and 6/2002 were identified. Their hospital charts were reviewed; demographics, perioperative data and outcomes were recorded. RESULTS: There were 24 patients (20 men, 4 women); mean age was 68+/-13 years (range 31-84 years). Ten patients had chronic lymphocytic leukemia, seven non-Hodgkin lymphomas, three multiple myeloma and one Hodgkin's disease, chronic myelocytic leukemia, hairy cell leukemia and cutaneous T-cell lymphoma each. The mean pre-operative duration of the hematologic disease was 6.6 years. Twenty-two patients underwent coronary artery bypass grafting (with valve replacement in three patients) and two patients had isolated valve replacement. There was one in-hospital death (4.1%). Twelve patients (50%) had a minor or major complication. Seven reoperations were required-five during the same admission (one for mediastinal bleeding, one for an expanding femoral pseudoaneurysm, one for acute cholecystitis and two for IACD/pacer insertion) and two within 30 days (one for deep sternal wound infection and one for leg wound infection). Mean post-operative stay was 8.2+/-5.8 days and mean ICU stay was 1.6+/-1.1 days. There were three late deaths-two were due to progression of the hematologic disease. The 3-year actuarial survival was 83%. CONCLUSIONS: Cardiac operations can be performed with acceptable mortality but significant morbidity rates in patients with hematologic malignancies. Bleeding and infectious complications are most frequently seen and usually lead to reoperations. These findings warrant caution during patient selection.     

Sevoflurane versus Halothane: Postoperative Maladaptive Behavioral Changes: A Randomized, Controlled Trial

Background: The authors conducted a double-blind, randomized, controlled trial to determine whether the use of sevoflurane in children undergoing anesthesia and surgery results in a higher incidence of postoperative maladaptive behavioral changes as compared with halothane.

Methods: Children and their parents (n = 102) were randomly assigned to either a halothane group (n = 50) or a sevoflurane group (n = 52). The intraoperative anesthetic protocol was strictly controlled, and the postoperative analgesic consumption and pain levels were recorded. The effect of the group assignment on emergence status and maladaptive postoperative behavioral changes was assessed both by validated psychological measures and physiologic instruments (actigraphy) on postoperative days 1-7. Anxiety of the parent and child was also assessed, as was the child's postoperative recovery (Recovery Inventory).

Results: There were no group differences in preoperative state anxiety, postoperative analgesic requirements, postoperative pain, or the incidence of emergence delirium (P = not significant). Two-way repeated-measures analysis of variance showed no group differences in the incidence of postoperative maladaptive behaviors (F4,72 = 0.60, P = 0.701) or actigraphic variables such as percent sleep, number of night awakenings, and night awakenings that lasted for more than 5 min (P = not significant).