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Twenty-eight patients (14 per 36% of patients on lithium by 1 year (79) 20 mg erectafil with amex. Thus purchase 20 mg erectafil, the drug treatment group) completed the study and were included relapse rates were very similar between studies but the pla- in the data analysis. There were no significant differences cebo relapse rate was much lower in the Bowden and co- in improvement between the two drugs on the BPRS and worker study (9). This disparity in placebo relapse rates is the Beigel-Murphy Manic State Rating Scale. First, although both stud- lithium-treated patients showed significantly greater im- ies standardized enrollment by an index manic episode, it provement in CGI change scores. In addition, only four is likely that patients in the Bowden and associates study (29%) of 14 CBZ-treated patients were considered respond- were less severely ill because only 18% had been hospitalized ers, whereas 11 (79%) of 14 lithium-treated patients re- during the index episode, whereas all patients in the Prien sponded. In the second lithium comparison study (88) 70% and colleagues study had been hospitalized. Second, the of 52 hospitalized patients randomized to lithium or CBZ definition of relapse differed between the studies. In the dropped out of the trial by 8 weeks owing to lack of efficacy. Two studies an initial year of treatment with lithium or CBZ, a crossover compared CBZ with chlorpromazine in the treatment of to the alternate drug in the second year, followed by a third acute mania (34,71). In the first comparison trial, 60 acutely year on the combination (23). Among evaluable patients, manic patients were randomized to either agent in a 6-week 13(31%) of 42 lithium-treated patients relapsed within 1 trial (71). There were no significant differences in efficacy year compared with 13 (37%) of 35 CBZ-treated patients. As in the previous study, a higher percentage of 28 patients receiving chlorpromazine. In the second study of patients receiving CBZ withdrew because of adverse (34,37) patients were randomized to CBZ (n 15) or events. The percentage of patients who had moderate or chlorpromazine (n 19) in a 3-week trial. Response was marked improvement on the CGI was not significantly dif- assessed in 26 patients who completed the trial. Patients ferent: 33% on lithium, 31% on CBZ, 55% on the combi- treated with CBZ (n 15) or chlorpromazine (n 11) nation; however, on a variety of measures of mania, lithium had comparable improvement. Finally, patients with a history were rated as displaying at least moderate improvement and of rapid cycling responded significantly better to the combi- 59% for the chlorpromazine group. In summary, data from nation (56% response) compared with lithium (28%) or these five trials suggest that CBZ is superior to placebo and CBZ (19%). STANDARD ANTIPSYCHOTICS Maintenance Acute Mania The efficacy of CBZ in the prevention of recurrent affective episodes has been a matter of controversy (22,77). This There is one double-blind, placebo-controlled study of a controversy rests in part on the heterogeneity among the standard antipsychotic in the treatment of acute bipolar early controlled maintenance studies (22,54,74,101), and mania (50). In that study, 13patients were randomized to the availability of only one placebo-controlled maintenance chlorpromazine (1,200 mg per day), imipramine (300 mg trial (70). Interpretation of this latter study is also limited per day), or placebo for 7 weeks. Response was assessed by the use of adjunctive rescue medications other than lith- using a global scale ranging from 9to 9. Chlorproma- ium and CBZ to treat breakthrough symptoms. The liberal zine was significantly superior to placebo and imipramine use of these adjunctive treatments thus limits the degree to on global outcome (6. Two recent large prospective, double-blind, long-term maintenance studies provide new data comparing the effi- Maintenance cacy of CBZ with lithium (23,33).

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Effects of dehydroepian- in phospholipid fatty acid composition and monoaminergic drosterone and its sulfate on brain tissue in culture and on neurotransmission in the hippocampus of rats fed a balanced memory in mice purchase erectafil 20 mg without a prescription. JNeurosci Res 1987;17: dietary deficiency alters age-related changes of dopaminergic 225–234 erectafil 20mg online. Do essential fatty acids play a role in brain development. The membrane phospholipid hypothesis as a 9:759–763. Potentiation of neu- sion, normalisation of blood fatty acids, reduced neuronal mem- ronal NMDA response induced by dehydroepiandrosterone and brane phospholipid turnover and structural brain changes. Int its suppression by progesterone: effects mediated via sigma re- JClin Pract 2000;54:57–63. Potentiation by de- of supplemental EPA for residual symptoms of schizophrenia. D-aspartate in the CA3 region of the rat dorsal hippocampus: 428. Implications of normal brain development for an effect mediated via sigma receptors. JEndocrinol (Suppl) the pathogenesis of schizophrenia. Selective modulation maldevelopmental hypothesis of schizophrenic psychoses. J of fibroblast growth factor-2 expression in the rat brain by the Neural Transm 1998;105:85–100. When neurotrophic factors get on your nerves: ther- 434. Iloperidone binding to apy for neurodegenerative disorders. JClin Psychiatry 1998;59: human and rat dopamine and 5-HT receptors. COVELL ECONOMICS OF MENTAL HEALTH AND economists indicate the range of activities in the field of SCHIZOPHRENIA mental health economics, including the economics of schiz- ophrenia. This chapter focuses on two aspects of the eco- Prior to the 1980s, economists paid scant attention to schiz- nomics of schizophrenia: cost studies and cost-effectiveness ophrenia, or indeed to mental health in general (1). Studies of the cost of mental illnesses appeared be- work in the field included efforts to consider the impact fore other types of work in the economics of mental health, of organization and financing on system efficiency and to and they have continued throughout the past two decades. For example, McGuire (2) reviewed the mar- cost-benefit studies because they identify the range of re- ket for psychotherapy and the insurability of mental health sources that are consumed as a result of an illness. Cost- care, and Frank (3) examined the supply of psychiatrists. The use of diagnosis- brod and colleagues (14) on the cost-benefit of assertive related groupings to pay for care under prospective payment community treatment teams. Collectively, studies of costs was considered by Taube and his colleagues (5). Dickey and cost-effectiveness are perhaps the most important foci and Goldman (6) reviewed the impact of various funding of the economics of schizophrenia. First, the sizable cost to mechanisms in public mental health. Observers of systems change consid- ered major reorganizational efforts, such as those imple- mented through the Robert Wood Johnson Program on Costs Of Schizophrenia Chronic Mental Illness (8) and other types of organizational reforms (9–12). The 1990s also brought analysis of the Early studies of the costs of mental illness (15–17) did not increasing implementation of managed care with behavioral distinguish between the costs of different diagnostic categor- health carve-outs (13). More recent studies have estimated specific costs These examples of the contributions of mental health for schizophrenia and other illnesses. Rice has estimated the cost of schizophrenia in the United States at $32. Goeree and colleagues (21) have calculated costs in Canada in 1996 to Susan M. Essock: Department of Psychiatry, Mount Sinai School of be approximately $2.

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Prevention of apoptosis by bcl- expressed by different populations of cortical neurons undergoing 2: release of cytochrome c from mitochondria blocked buy discount erectafil 20 mg line. Science delayed cell death after focal stroke in the rat purchase erectafil 20mg otc. Lasting N-terminal cytochrome c from mitochondria: a primary site for bcl-2 regula- phosphorylation of c-jun and activation of c-jun N-terminal ki- tion of apoptosis. Biosci Rep 1997;17:67– kinase inhibition protects against damage resulting from focal 76. Immunoreactive akt, pi3- chrome c release in isolated mitochondria. Proc Natl Acad Sci k and erk protein kinase expression in ischemic rat brain. Early detection of DNA strand nel-forming activity by bcl-2. Bax-induced cyto- for the role of DNA damage in apoptosis and neuronal cell death. P53 expression in brain after the cytosol to mitochondria during apoptosis. J Cell Biol 1997; middle cerebral artery occlusion in the rat. Expression of the apoptosis- of the programmed cell death regulator bad in the rat brain. Apoptosis regulated by a death factor and its receptor: 64–71. TNF, apoptosis and autoimmunity: a com- 1995;15:6364–6376. Bid-deficient mice are resistant sion of bcl-2 in transgenic mice protects neurons from naturally to fas-induced hepatocellular apoptosis. Nature 1999;400: occurring cell death and experimental ischemia. Expression of bcl- mitochondria and is required for cytochrome c release, while bcl- 2 from a defective herpes simplex virus-1 vector limits neuronal xl prevents this release but not tumor necrosis factor-r1/fas death. FASEB J 1995; viral vectors expressing bcl-2 are neuroprotective when delivered 9:726–735. Suppression of endoge- antigen MRNA induced in postischemic murine forebrain by in nous bcl-2 expression by antisense treatment exacerbates ischemic situ hybridization. Attenuation of transient focal ligand mediate ischemia-induced apoptosis in neurons. J Neurosci cerebral ischemic injury in transgenic mice expressing a mutant 1999;19:3809–3817. Inhibition of and in vivo and is upregulated following cerebral hypoxic– interleukin 1beta converting enzyme family proteases reduces is- 1326 Neuropsychopharmacology: The Fifth Generation of Progress chemic and excitotoxic neuronal damage. Proc Natl Acad Sci duced neuronal death: a succession of necrosis or apoptosis de- USA 1997;94:2007–2012. Apoptosis and necro- protease may mediate delayed neuronal death in the hippocampus sis: two distinct events induced, respectively, by mild and intense after transient cerebral ischemia. J Neurosci 1998;18:4914– insults with N-methyl-D-aspartate or nitric oxide/superoxide in 4928. BUCHAN Stroke is the third leading cause of death in the United blood flow owing to vascular occlusion. The remaining 20% States; approximately 730,000 Americans have a new or of strokes result from cerebral hemorrhage. In global models, the entire forebrain incidence of stroke is expected to rise dramatically as the is made ischemic for a brief period (5 to 20 minutes) and population ages because stroke risk increases with age. After a significant delay ( 3 days), selective risk of stroke doubles for each decade after age 55. Stroke neuronal death evolves in layers III, V, and VI of the cortex, is a major factor in the late-life dementia that affects more the CA1 region of the hippocampus, and the striatum than 40% of Americans over the age of 80. These models are representative of cardiac arrest and men will have had a disabling stroke by the age of 80 and coronary artery bypass surgery rather than clinical stroke. In focal models, the middle cerebral artery is occluded for Currently Alteplase (recombinant tissue plasminogen ac- a more prolonged period (60 to 120 minutes in temporary tivator [rtPA]) is the only treatment for acute stroke ap- models and permanently in permanent occlusion models).

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CAG/CTG repeats detected by RED could be explained by The current balance of evidence favors the view that the polymorphisms at these two loci erectafil 20mg, which suggests that at high prevalence of psychosis results from hemizygosity for least one further locus is responsible for the RED data order erectafil 20mg mastercard, a a gene or genes at chromosome 22q11 rather than ascertain- possibility supported by two recent studies on protein ex- ment bias or a nonspecific association with a low intelligence tracts from schizophrenic tissues (143). In particular, the prevalence of psy- chosis and schizotypy in VCFS appears to be much greater than that seen in most other congenital abnormalities affect- HIGH RATES OF SCHIZOPHRENIA IN ing neural development, and appears not to be correlated ADULTS WITH VELOCARDIOFACIAL with the degree of intellectual impairment (149). Many SYNDROME lines of evidence suggest that schizophrenia is a neurodevel- opmental disorder (150). In VCFS, defective development Velocardiofacial syndrome (VCFS), also known as DiGeorge and migration of mesencephalic and cardiac neural crest or Shprintzen syndrome, is associated with small interstitial cells are believed to play a significant role in the pathogenesis deletions of chromosome 22q11 in 80% to 85% of cases of midfacial and cardiac abnormalities (151). First described by Shprintzen and colleagues (145), it has been postulated that a gene or genes causing disrup- VCFS has an estimated prevalence of 1/4,000 births (146). As the first rec- What then is the importance of 22q11 and VCFS in the ognized cohort of children with VCFS was followed into etiology of schizophrenia as a whole? Early tients with schizophrenia, two were found to have a 22q11 reports suggested that psychiatric disorders had developed deletion. In contrast, when subjects with schizophrenia were in more than 10% of the cohort, which mostly resembled selected for the presence of clinical features consistent with chronic schizophrenia with paranoid delusions, although VCFS, 22q11 deletions were identified in 20% to 59% of operational criteria were not used (147). These findings suggest that a small propor- study of teenagers (age 17 years) in which DSM-III-R crite- tion of cases of schizophrenia may result from deletions of ria were used, Pulver et al. The question of whether genetic depression, and 14% had obsessive-compulsive disorder. As sample of 15 children and 10 adults, four (16%) had psy- we have seen, the results of some linkage studies suggest chotic symptoms and 16 (64%) met DSM-III-R criteria for the presence of a schizophrenia susceptibility locus on 22q. Although none However, the linkage findings tend to point telomeric to had schizophrenia, the two oldest members of their patient the VCFS region (86,157). Nevertheless, modest evidence cohort (ages 29 and 34 years) both had schizoaffective dis- for linkage to the VCFS region has also been claimed (90, order. It remains possible lence and nature of psychopathology in adults with VCFS, that the relationship between VCFS and 'typical' schizo- rather than rely on clinical diagnosis, Murphy and col- phrenia is less direct, with little common ground between leagues (149) recently evaluated 50 cases with a structured the genetic and neurodevelopmental mechanisms involved clinical interview to establish a DSM-IV diagnosis. Fifteen but with convergence on identical or at least similar psycho- patients with VCFS (30%) had a psychotic disorder, with pathologic syndromes. Another important question concerns the factors that In addition, six (12%) had major depression without psy- determine whether schizophrenia will develop in a person chotic features. They were unable to replicate the findings with VCFS. When adults with VCFS were tested with a of Papolos and colleagues (146) of a high prevalence of quantitative measure of schizotypy, the patients with psy- bipolar spectrum disorders in VCFS. However, these work- chosis had the highest scores (149). However, perhaps of ers studied a small sample that included few adults, and in greater interest, those without psychosis had intermediate 680 Neuropsychopharmacology: The Fifth Generation of Progress scores in comparison with controls (149). If schizotypy is are clinical symptoms—so-called intermediate phenotypes a trait marker for increased liability to psychosis, this sug- or endophenotypes. Work in this area is developing fast; for gests that the majority if not all of those with 22q11 dele- example, candidate trait markers for schizophrenia include tions are at increased risk for psychosis, but that other ge- schizotypal personality traits, measures of cognitive process- netic or environmental factors are required for this risk to ing, brain evoked potentials, and abnormalities in eye move- be expressed. The genetic loci involved may reside elsewhere ments (163). It is also hoped that advances in brain imaging in the genome and include those involved more widely in will lead to the identification of genetically valid trait mark- psychosis, or lie within 22q11. However, it seems unlikely that these phenotypes will does not appear to be related to the size of the deletion provide a rapid solution to the problem. However, it is possible that susceptibility to psychosis to ensure that the measures used are stable and determine reflects allelic variation of a hemizygous gene or genes within the extent to which they are affected by state. The gene encoding catechol-O-methyltransfer- be of use in gene mapping, such measures will have to be ase (COMT), an enzyme involved in the catabolism of cate- practicably applied to a sufficient number of families or cholamine neurotransmitters, maps to the VCFS region and unrelated patients. Third, we will need to ensure that the is therefore an obvious candidate for influencing the expres- traits identified are highly heritable, which will itself require sion of psychosis in VCFS probands. This gene exists in a return to classic genetic epidemiology and model fitting. However, concerned with enhancing the traditional categoric ap- Murphy and colleagues (149) found no evidence for an proach to defining psychiatric disorders by identifying ge- association between the allele for low-activity COMT and netically valid phenotypes that can be measured quantita- either schizophrenia or schizotypy in patients with VCFS.

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