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The latest research from Family Relations shows that parents in lowincome environments are more prone to depression when there is a lack of social support.

This is especially prevalent in rural regions, where mental health and social resources can be deficient.

Social support mechanisms such as community groups, churches, and school or sportsrelated activities, can act as a barrier against negative thinking and allow parents who are prone to depression, in order to make better, more positive choices and engage in healthy parental practices.

The findings support a holistic care plan for families in need, combining skillbased interventions with social recommendations.

These measures may help to decrease the detrimental effects of economic stress on individual and family functioning.

Identification of criteria for the detection of prolonged grief disorder (PGD) appear able to identify bereaved persons at heightened risk for enduring distress and dysfunction, says a new study in this weeks open access journal PLoS Medicine. The results support the psychometric validity of the criteria for PGD and should be included in the Diagnostic Statistical Manual of Mental Disorders, 5th Edition (DSMV) and the International Statistical Classification of Diseases and Related Health Problems (ICD11), say the authors.

Dr. Holly Prigerson from the Dana Farber Cancer Institute in Boston, Massachusetts and her colleagues conducted a field trial to develop and evaluate algorithms for diagnosing PGD based on a set of symptoms agreed upon by experts in bereavement, mood and anxiety disorders, and psychiatric nosology.

They interviewed 291 bereaved individuals three times in the two years following the loss of a spouse about their experiences of these symptoms. Using item response theory and combinatoric analysis, the researchers identified the most sensitive and specific algorithm for the diagnosis of PGD. This algorithm included yearning (physical or emotional suffering because of an unfulfilled desire for reunion with the deceased) and at least five of nine additional symptoms including emotional numbness, feeling that life is meaningless, and avoidance of the reality of the loss, which had to have persisted for at least 6 months after the bereavement and to be associated with functional impairment.

In addition, the researchers report that individuals in their study given a diagnosis of PGD 612 months after a death had a higher subsequent risk of mental health and functional impairment than people not diagnosed with PGD.

Currently, grief is not recognized as a mental disorder in the DSMIV or the ICD10.

The authors say that their work confirms the distinctiveness of the symptoms of PGD, and “that PGD meets DSM criteria for inclusion as a distinct mental disorder on the grounds that it is a clinically significant form of psychological distress associated with substantial disability.”

In an accompanying Perspective article, Dr. Stephen Workman (not involved in the research) from the Queen Elizabeth II Health Sciences Center in Halifax, Nova Scotia, Canada, says that by persuasively establishing PGD as a uniquely identifiable illness that may require specific treatments, Dr. Prigerson and colleagues have separated PGD from normal grief and from other forms of pathologic grief responses. He says from a clinicians perspective that the work is “rigorous, compassionate, and humane.”

Article by Dr Prigerson and Colleagues

Funding HGP was supported by National Institute of Mental Health grants MH56529 and MH63892, and National Cancer Institute grant CA106370. PKM was supported by NIH grant NS044316. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing Interests Michael First received consultant fees over the past 5 years from Roche, Corcept, Wyeth, Cephalon, AstraZeneca, Shire, GSK, and Eli Lilly for preparing diagnostic interviews and/or conducting diagnostic trainings at investigator meetings.

One of the most wellknown psychological tools is the Rorschach Inkblot Test. A viewer looks at ten inkblots, one at a time, and describes what they see. The rationale behind this test is the idea that certain aspects of the subjects personality will be exposed as they are interpreting the images, allowing for the possible diagnosis of various psychological disorders. However, does the inkblot really reveal all? Psychological Science in the Public Interest, a journal of the Association for Psychological Science, published an exhaustive review of all data on the Rorschach (and other similar “projective” tests) in 2000. Such metaanalyses are major undertakings, so although this report is a few years old, it remains the most definitive word on the Rorschach. According to authors Scott O. Lilienfeld of Emory University, James M. Wood of University of Texas at El Paso, and Howard N. Garb of the University of Pittsburgh, despite its popularity, the Rorschach may not be the best diagnostic tool and practitioners need to be cautious in how they use this technique and interpret their results.

The Rorschach Inkblot Test was developed in the 1920s, but was already mired in controversy within 30 years (critics argued that it was not always administered in a standardized way and evidence for its reliability was lacking). However, the Rorschach was revived in the 1970s with the publication of John Exners Comprehensive System (CS), which detailed standards and norms for analyzing results. The CS was credited with providing a concrete, scientific basis for the Rorschach tested and it became widely used in clinical and forensic settings.

Proponents of the CS claimed that it also provided a wealth of information for nonpatient adults and children. However, critics of this system argue that the norms established by CS are out of date and based on small sample sizes. Furthermore, the CS norms are not representative of the population and actually classify a portion of normal subjects as having pathological tendencies. Many studies have also called into question the scoring reliability of the CS; that is, a number of experiments have shown that two practitioners will score one subject very differently using the CS method. The authors observe that “disagreements can have particularly serious implications if the test results are used to reach important clinical or legal recommendations.”

In addition, some studies suggest that there may be a cultural bias associated with the CS. Research has shown that Blacks, Hispanics, and Native Americans score differently on a number of variables in the CS compared to White Americans. The authors note that “similar discrepancies have been reported for CS scores in Central and South American countries as well as in several European countries.” These findings suggest that any CS data acquired from various racial and cultural groups should be interpreted with extreme caution.

The authors acknowledge that not all the news concerning the Rorschach Inkblot Test is bad There is evidence that this tool may be useful in identifying patients with schizophrenia, bipolar disorder, and borderline personality disorder. They note, however, that the Rorschach has not been shown to be related to Major Depressive Disorder, Antisocial Personality Disorders, or Posttraumatic Stress Disorder.

Overall, the authors suggest that due to the inconsistent literature on the Rorschach Inkblot Test and other related psychological tools, practitioners should be very selective when they use these assessments and use them in ways which have strong empirical support. “Whenever possible,” the authors conclude, “forensic and clinical evaluations should be based on more dependable assessment techniques, such as structured psychiatric interviews and wellvalidated selfreport indexes.”

Source
Barbara Isanski

Depression in older adults too often goes unrecognized and untreated, resulting in untold misery, worsening of medical illness, and early death. A new study has identified one important remedy Adding a trained depression care manager to primary care practices can increase the number of patients receiving treatment, lead to a higher remission rate of depression, and reduce suicidal thoughts.

The twoyear outcomes of the multicenter Prevention of Suicide in Primary Care Elderly Collaborative Trial (PROSPECT) study are published online in the American Journal of Psychiatry.

Lead author of the study is Dr. George S. Alexopoulos, director of the Institute of Geriatric Psychiatry at NewYorkPresbyterian Hospital/Westchester Division and professor of psychiatry at Weill Cornell Medical College.

“Almost one in 10 older adults in the United States has some form of depression, and onefifth among them contemplates suicide. Twothirds of these patients are treated by primary care physicians. Sadly, their depression is often inadequately treated due to the primary care physicians time constraints and the patients reluctance to discuss their symptoms and adhere to treatment,” says Dr. Alexopoulos. “The critical finding of the PROSPECT study is that adding a trained care manager to primary care practices increases the number of depressed older patients who receive treatment and improves their outcomes, not only in the short term, but over two years.

“This is important because depression can either become chronic or relapse after an initial improvement,” adds Dr. Alexopoulos. “Most diseases have worse outcomes when an old person becomes depressed. Depression almost doubles the risk for death. It follows that treating depression effectively can reduce sickness, disability and death.”

The study, conduced by NewYork Presbyterian/Weill Cornell, the University of Pittsburgh, and the University of Pennsylvania, followed 599 patients aged 60 years and older with depression at 20 primary care practices of varying sizes in New York and Pennsylvania. Participants were randomized to receive either the PROSPECT intervention or usual care. Those in the PROSPECT group were assigned a care manager a trained social worker, nurse or psychologist who helped the physician offer treatment according to accepted practice guidelines, monitored treatment response and provided followup over two years. Practice guidelines included the antidepressant citalopram (Celexa), with the option of other drugs or psychotherapy.

After two years, nearly 90 percent of patients in the PROSPECT care management group had received treatment for depression, compared with 62 percent of those receiving usual care by their physicians. The decline in suicidal ideation (thinking about and/or planning suicide) was 2.2 times greater in the PROSPECT group.

Remission of depression happened faster in the PROSPECT intervention group and remission rates continued to increase between months 18 and 24, while no appreciable increase occurred in the usual care group during the same period.

The PROSPECT intervention worked especially well for a subgroup of patients with major depression, the more severe form of the disease, with a greater number achieving remission, or the near absence of symptoms. Patients with minor depression had favorable outcomes regardless of their study group.

Various forms of care management are being used successfully for cardiovascular patients needing anticoagulation medication and for diabetes patients needing insulin monitoring, says Dr. Alexopoulos. “The PROSPECT study has demonstrated that care management is highly successful for older adults with major depression.”

“At this time, our nation is focused on disease prevention as a way to improve the health of Americans and to reduce health care cost. Reducing depression over long periods of time can be one of the ways to achieve this objective,” continues Dr. Alexopoulos. “Care management, like that of the PROSPECT study, is relatively inexpensive. Finding ways to reimburse it can make it broadly available and have a major impact on the overall heath care.”

Dr. Alexopoulos serves as a paid member of the speakers bureau and a paid member of the Scientific Advisory Board for Forest Laboratories Inc., the maker of the antidepressant drug citalopram (Celexa). Forest offered free citalopram and a small stipend to support the study.

Coauthors include Drs. Martha L. Bruce and Patrick J. Raue of NewYorkPresbyterian/Westchester and Weill Cornell Medical College; Dr. Charles F. Reynolds III of the University of Pittsburg; Drs. Ira R. Katz, David W. Oslin and Thomas Ten Have of the University of Pennsylvania; and Dr. Benoit H. Mulsant of the University of Toronto.

NewYorkPresbyterian Hospital/Westchester Division

NewYorkPresbyterian Hospital/Westchester Division, opened in 1894, is one of the worlds most advanced centers for psychiatric care. The Westchester Division serves children, adolescents, adults and the elderly with comprehensive outpatient, day treatment, partial hospitalization and inpatient services. In addition to clinical treatment, the Westchester Division is also a center for interdisciplinary medical research and education through its academic affiliate, Weill Cornell Medical College. NewYorkPresbyterian Hospital also comprises NewYorkPresbyterian Hospital/Weill Cornell Medical Center, NewYorkPresbyterian Hospital/Columbia University Medical Center, NewYorkPresbyterian Morgan Stanley Childrens Hospital and NewYorkPresbyterian Hospital/The Allen Pavilion. NewYorkPresbyterian is the #1 hospital in the New York metropolitan area and is consistently ranked among the best academic medical institutions in the nation, according to U.S.News & World Report.

The Nintendo Wii may help treat symptoms of Parkinsons disease, including depression, a Medical College of Georgia researcher says.

Parkinsons disease is a degenerative disease that impairs motor skills. Dr. Herz theorized that the popular computer game console, which simulates various sports and activities, could improve coordination, reflexes and other movementrelated skills, but he found additional benefits as well.

“The Wii allows patients to work in a virtual environment thats safe, fun and motivational,” says Dr. Ben Herz, program director and assistant professor in the School of Allied Health Sciences Department of Occupational Therapy. “The games require visual perception, eyehand coordination, figureground relationships and sequenced movement, so its a huge treatment tool from an occupational therapy perspective.”

In an eightweek pilot study, 20 Parkinsons patients spent an hour playing the Wii three times a week for four weeks. The patients, all in a stage of the disease in which both body sides are affected but with no significant gait disturbance yet, played two games each of tennis and bowling and one game of boxinggames entailing exercise, bilateral movement, balance and fast pace.

“By the middle of the study, we actually had a number of people who could [defeat] their opponent out in the first round, which amazed us,” says Dr. Herz, who presented his preliminary findings at the fifth annual Games for Health Conference in Boston.

The victories werent the biggest surprise, however. Participants showed significant improvements in rigidity, movement, fine motor skills and energy levels. Perhaps most impressively, most participants depression levels decreased to zero.

An estimated 45 percent of Parkinsons patients are reported to suffer from depression, though Dr. Herz suspects the actual figure is much higher.

Studies have shown that exercise and video games independently can increase the production of dopamine, a neurotransmitter deficient in Parkinsons patients. He suspects thats the case with the Wiis exercise effect. Dopamine also helps improve voluntary, functional movements, which Parkinsons patients “use or lose,” Dr. Herz says.

Wii, which features simulated movements such as cracking an egg, swinging a tennis racket and throwing a bowling ball, responds to a players movements rather than cues from a controller, so players can do full body movements and see their progress on a screen.

“I think were going to be using virtual reality and games a lot more because it provides a controlled physical environment that allows patients to participate in the activities they need or want to do. A patient doesnt have to go to a bowling alley and worry about environmental problems or distractions,” Dr. Herz says.

Dr. Herzs research was funded by a $45,000 grant from the National Parkinsons Foundation. Next he plans to test the Wii Fit balance board with Parkinsons patients and expand his studies to multiple sites.

“Game systems are the future of rehab,” Dr. Herz says. “About 60 percent of the study participants decided to buy a Wii for themselves. That speaks volumes for how this made them feel.”

Source
Paula Hinely
Medical College of Georgia

Teenagers who dont express their emotions are more likely to suffer from depressive symptoms. This is the finding of a study published in the British Journal of Developmental Psychology.

The study, carried out by Jennifer Betts, Eleonora Gullone and Sabura Allen at Monash University, Melbourne, Australia, looked at the emotion regulation strategies of 44 teenagers aged 12 to 16 with a high level of depressive symptoms and compared them to the strategies of 44 adolescents with no symptoms.

Eleonora Gullone said “We found that the teenagers with symptoms of depression suppressed the expression of their emotions significantly more than their nondepressed peers. The teenagers with no depressive symptoms instead reported high levels of cognitive reappraisal these teenagers were able to think about potentially negative events and reframe them in a more positive way. For example, rather than seeing a poor assignment grade as a sign of failure, they would see it as a way to improve their future performance.

“As depression is a debilitating disorder its important that we understand more about the emotion regulation strategies that depressed adolescents are using. By doing so we can develop psychological therapies that target problem strategies and reduce depressive thinking.”

The study also discovered that more depressed teens reported having less caring, more overprotective parents than the nondepressed group. However it is unclear from this study whether perceived parenting style was a cause or was a result of the adolescents depressive symptoms.