Discovery Of Genetic Link To Children's Emotional Problems Precipitated By Bullying

Bullying victimization is common among children of school age, although its consequences are often anything but benign. The recent death of a Massachusetts teen by suicide prompted state lawmakers to pass one of the most far-reaching anti-bullying laws within the U.S. Whether such legislative actions result in measurable decreases in physical or emotional distress among school peers remains to be seen, but a team of researchers from Duke University and Kings College London have discovered a genetic variation that moderates whether victims of bullying will go on to develop emotional problems.



Gene and environment interactions are a burgeoning area of scientific research and an increasing body of evidence demonstrates that children who are victims of bullying are at risk for developing emotional problems including depression. However, not all children who are bullied go on to develop such problems. Whether a gene variant could contribute to emotional disturbance in children that are bullied is the focus of a study reported in the August 2010 issue of the Journal of the American Academy of Child and Adolescent Psychiatry (JAACAP).



In the article titled, "The Serotonin Transporter Gene Moderates the Development of Emotional Problems Among Children Following Bullying Victimization" Dr. Sugden and colleagues report on the findings in a study sample of 2,232 same-sex 5 year-old twins. Home visit-assessments were conducted in 1999-2000 when the children were 5 years of age, and follow-up assessments were made at 12 years of age. The children were evaluated for emotional problems reported by their mothers and teachers using the Child Behavior Checklist and the Teacher's Report Form. In addition to interviews, DNA samples acquired via buccal swabs were evaluated to determine the presence or absence of the genetic variation under investigation.



The researchers observed that genetic differences in the 5-HTTLPR gene, specifically the SS genotype, interact with bullying victimization to exacerbate emotional problems. Second, the strength of this genetically influenced response is related to the frequency of the bullying experience (i.e., the gene and environment interaction was strongest for frequently bullied children).



In the article, Sudgen and colleagues state, "This genetic moderation persists after controlling for children's previctimization emotional problems and for other risk factors shared by children growing up within the same family environment." The present findings are consistent with the recent report by Benjet and colleagues2 that SS genotype victims of relational aggression are prone to depression.



This article is discussed in an editorial by Dr. James J. Hudziak and Dr. Stephen V. Faraone in the Journal of the American Academy of Child and Adolescent Psychiatry. 3 In talking about the use of twin studies to determine whether an illness or psychological disorder can be inherited, Drs. Hudziak and Faraone state, "These designs have moved us well beyond the fiery but misguided debates about nature versus nurture. We have learned that both domains affect psychopathology, exerting effects that sometimes act independently of one another and sometimes interactively, as when risk DNA variants make some children more susceptible to the onset of illness. Twin studies show that gene action can be complex, with DNA variants at a gene locus sometimes acting additively (in a dose-response manner) and sometimes with classic dominant or recessive modes of inheritance."
















On the relevance of Dr. Sugden and colleagues' findings, Drs. Hudziak and Faraone report, "Candidate gene studies such as these could lead to public health interventions (e.g. greater efforts to decrease bullying) that may lower the prevalence of child psychopathology." 3



Notes:

This study was supported by the UK Medical Research Council grants G9806489, G0100527, and G0601483, and National Institutes of Health grants MH077874 and HD061298.


The study is published in the Journal of the American Academy of Child and Adolescent Psychiatry and online here. This article represents one of several articles to be published in the August and September issues of the Journal of the American Academy of Child and Adolescent Psychiatry that explores the intersection of genetics and mental health disorders in children and adolescents.



References:


1. Sugden K, Arseneault L, Harrington H, Moffitt TE, Williams B, Caspi A. The Serotonin transporter gene moderates the development of emotional problems among children following bullying victimization. Journal of the American Academy of Child and Adolescent Psychiatry. 2010; 49:830-840.


2. Benjet C, Thompson RJ, Gotlib IH. 5-HTTLPR moderates the effect of relational peer victimization on depressive symptoms in adolescent girls. J Child Psychol Psychiatry Allied Disc. 2009;51:173-179.


3. Hudziak JJ, Faraone SV. The new genetics in child psychiatry. Journal of the American Academy of Child and Adolescent Psychiatry. 2010; 49:729-735.

Access To Health Care For Children Ages 10 To 19 Lacking, According To Report

U.S. residents between ages 10 and 19 do not receive adequate medical care, according to a report recently released by the National Research Council and the Institute of Medicine, the AP/Arizona Daily Star reports. The report found that the system of care for adolescents lacks coordination and proper design, as few physicians specialize in care for teens or provide comprehensive care that they trust. According to the report, fewer than 500 doctors had certification as adolescent medicine specialists between 1996 and 2005. Only a small percentage of adolescents have undergone screenings for risky behaviors that would allow physicians to intervene, the report found. Most adolescents visit physicians regularly, but the examinations that they receive often do not adequately assess their health risks, according to the report.

Although rates of pregnancy and smoking among adolescents have decreased in the past 10 years, the report found that improvements in the health of adolescents remain limited. In addition, physical activity among adolescents has decreased in the past 10 years, and rates of chronic diseases such as asthma and diabetes have increased, the report found. The report also found that, although between 10% and 20% of adolescents annually experience a mental health disorder such as anxiety or depression, their access to specialized mental health care has decreased in the past 10 years (Neergaard, AP/Arizona Daily Star, 1/6).


Reprinted with kind permission from kaisernetwork. You can view the entire Kaiser Daily Health Policy Report, search the archives, or sign up for email delivery at kaisernetwork/dailyreports/healthpolicy. The Kaiser Daily Health Policy Report is published for kaisernetwork, a free service of The Henry J. Kaiser Family Foundation.

© 2008 Advisory Board Company and Kaiser Family Foundation. All rights reserved.

Opiate Abuse And Protracted Abstinence

Opiate abuse is a chronic disorder and maintaining abstinence represents a major challenge for addicts.



Individuals recovering from opiate dependence have long reported that while the acute withdrawal symptoms from opiates may pass relatively quickly, they do not feel quite right for several weeks or even months thereafter. Called the "protracted abstinence syndrome," this cluster of vague depressive-like symptoms can include reduced concentration, low energy level, poor sleep quality, and anhedonia.



New data in animals, reported in Biological Psychiatry, now implicates the serotonin system in this phenomenon.



French researchers found that mice with chronic morphine exposure showed decreasing physical dependence during a period of abstinence, with no physical withdrawal symptoms after 4 weeks. In contrast, low sociability and despair behavior clearly developed after 4 weeks of abstinence.



Remarkably, treatment during the abstinence period with the antidepressant fluoxetine prevented the development of both social aversion and despair behavior.



This is important because fluoxetine targets the serotonin system, which is known to influence mood.



Senior author Dr. Brigitte Kieffer explained that this study "establishes a direct link between morphine abstinence and depressive-like symptoms, and strongly suggests a causal effect of serotonin dysfunction in depressive features associated with abstinence."



"The greatest risk associated with protracted abstinence is relapse to drug use," comments Dr. John Krystal, Editor of Biological Psychiatry. "This study provides new insights into a process that may contribute to relapse."



These findings should foster novel research along serotonergic pathways in drug abuse. It is hoped that these findings can lead to real-world clinic use, since serotonergic medication is already broadly available.


Notes:


The article is "Impaired Emotional-Like Behavior and Serotonergic Function During Protracted Abstinence from Chronic Morphine" by Celia Goeldner, Pierre-Eric Lutz, Emmanuel Darcq, Thomas Halter, Daniel Clesse, Abdel-Mouttalib Ouagazzal, and Brigitte L. Kieffer. Clesse is affiliated with Institut des Neurosciences Cellulaires et Int?©gratives, Centre National de la Recherche Scientifique, Strasbourg, France. All other authors are affiliated with Institut de G?©n?©tique et de Biologie Mol?©culaire et Cellulaire, Centre National de la Recherche Scientifique/Institut National de la Sant?© et de la Recherche M?©dicale/Universit?© de Strasbourg, Illkirch, France. The article appears in Biological Psychiatry, Volume 69, Number 3 (February 1, 2011), published by Elsevier.



The authors' disclosures of financial and conflicts of interests are available in the article.



John H. Krystal, M.D. is Chairman of the Department of Psychiatry at the Yale University School of Medicine and a research psychiatrist at the VA Connecticut Healthcare System. His disclosures of financial and conflicts of interests are available as a pdf here.

APA Welcomes FDA Antidepressant Label Changes Saying That Untreated Depression Is Greatest Risk Factor For Suicide

Today, the American Psychiatric Association (APA) welcomed labeling changes from the Food and Drug Administration (FDA), which apply to antidepressant use in adults. The FDA's new labeling acknowledges, for the first time, that untreated depression puts people at risk for suicide. The FDA label will continue to offer guidance on antidepressant treatments and suicidal thoughts and behaviors, sometimes referred to as "suicidality." While the medications are generally acknowledged to protect against completed suicides, some analyses, notably of younger patients, raise concerns about small increases in reports of suicide-related thinking and behaviors.


In response to the FDA announcement, Carolyn Robinowitz, M.D., president-elect of the APA, issued the following statement:



"We welcome today's announcement from the FDA as a major step in the right direction. Specifically, we are pleased that the agency is changing the label on antidepressants to acknowledge, for the first time, that it is untreated depression that puts people at the greatest risk for suicide. This change in labeling is supported by the science. The agency clearly heard its own advisors - the Psychopharmacologic Drugs Advisory Committee - and physicians and patients, all of whom came together at a hearing last Dec. 13 to tell the agency what labeling would best meet patients' needs. While some participants at that hearing called for drastic labeling changes that would have further restricted access to these lifesaving medications, the FDA wisely acted in patients' best interests.


Studies have shown that the old labeling - a black box warning label that the agency had issued in 2004 - was associated with a steep decline in treatment rates. Worse, the 2004 labeling change was followed by an increase in the suicide rate, reversing a decade-long decline in suicide deaths in the United States.



We believe the new label, which still contains important warning information, reminds physicians and patients that antidepressants save lives. Physicians and patients need all the facts in order to make appropriate, informed decisions about any proposed course of treatment.



Finally, we continue to encourage the FDA to formally monitor the effects of its labeling changes."



About the American Psychiatric Association


The American Psychiatric Association is a national medical specialty society whose more than 38,000 physician members specialize in diagnosis, treatment, prevention and research of mental illnesses including substance use disorders. Visit the APA at psych and HealthyMinds.

Link Found Between Depression And Household Mold

A groundbreaking public health study has found a connection between damp, moldy homes and depression. The study, led by Brown University epidemiologist Edmond Shenassa, is the largest investigation of an association between mold and mood and is the first such investigation conducted outside the United Kingdom.



Shenassa said the findings, published in the American Journal of Public Health, came as a complete surprise. In fact, after a few U.K. studies published in the last decade had suggested a link, Shenassa and his skeptical team set out to debunk the notion that any link existed.



"We thought that once we statistically accounted for factors that could clearly contribute to depression -- things like employment status and crowding -- we would see any link vanish," said Shenassa, the lead author of the study and an associate professor in the Department of Community Health at Brown. "But the opposite was true. We found a solid association between depression and living in a damp, moldy home."



Shenassa noted the study, an analysis of data from nearly 6,000 European adults, does not prove that moldy homes cause depression. The study wasn't designed to draw that direct conclusion. However, Shenassa's team did find a connection, one likely driven by two factors. One factor is a perceived lack of control over the housing environment. The other is mold-related health problems such as wheezing, fatigue and a cold or throat illness.



"Physical health, and perceptions of control, are linked with an elevated risk for depression," Shenassa said, "and that makes sense. If you are sick from mold, and feel you can't get rid of it, it may affect your mental health."



The study was a statistical analysis of data from the Large Analysis and Review of European Housing and Health Status (LARES), a survey on housing, health and place of residence conducted in 2002 and 2003 by the World Health Organization (WHO). To conduct the survey, WHO interviewers visited thousands of homes in eight European cities and asked residents a series of questions, including if they had depressive symptoms such as decreased appetite, low self-esteem, and sleep disturbances. WHO interviewers also made visual checks of each household, looking for spots on walls and ceilings that indicate mold.



Shenassa's team analyzed LARES data from 5,882 adults in 2,982 households.



"What the study makes clear is the importance of housing as indicator of health, including mental health," Shenassa said. "Healthy homes can promote healthy lives."



Shenassa and his team are conducting follow-up research to see if mold does, indeed, directly cause depression. Shenassa said that given the results of the current study, he wouldn't be surprised if there is a cause-and-effect association. Molds are toxins, and some research has indicated that these toxins can affect the nervous system or the immune system or impede the function of the frontal cortex, the part of the brain that plays a part in impulse control, memory, problem solving, sexual behavior, socialization and spontaneity.







The research team includes Allison Liebhaber, a former Brown undergraduate; Constantine Daskalakis of Thomas Jefferson University; Matthias Braubach of WHO; and Mary Jean Brown of the Harvard School of Public Health.

Americans Show Little Tolerance For Mental Illness Despite Growing Belief In Genetic Cause

A new study by University of Pennsylvania sociology professor Jason Schnittker shows that, while more Americans believe that mental illness has genetic causes, the nation is no more tolerant of the mentally ill than it was 10 years ago.



The study published online in the journal
Social Science
and Medicine uses a 2006 replication of the 1996 General Social Survey Mental Health Module to explore trends in public beliefs about mental illness in America, focusing in particular on public support for genetic arguments.



Prior medical-sociology studies reveal that public beliefs about mental illness reflect the dominant mental-illness treatment, the changing nature of media portrayals of the mentally ill and the prevailing wisdom of science and medicine.



Schnittker's study, "An Uncertain Revolution: Why the Rise of a Genetic Model of Mental Illness Has Not Increased Tolerance," attempts to address why tolerance of the mentally ill hasn't increased along with the rising popularity of a biomedical view of its causes. His study finds that different genetic arguments have, in fact, become more popular but have very different associations depending on the mental illness being considered.


"In the case of schizophrenia, genetic arguments are associated with fears regarding violence," Schnittker said. "In fact, attributing schizophrenia to genes is no different from attributing it to bad character - either way Americans see those with schizophrenia as 'damaged' in some essential way and, therefore, likely to be violent. However, when applied to depression, genetic arguments have very different connotations: they are associated with social acceptance. If you imagine that someone's depression is a genetic problem, the condition seems more real and less blameworthy: it's in their genes, they're not weak, so I should accept them for who they are."


Schnittker's study also shows that genetic arguments are associated with recommending medical treatment but are not associated with the perceived likelihood of improvement.


"While the stigma surrounding mental illness has not diminished, the rate of treatment for psychiatric disorders has increased," Schnittker wrote. "The culture surrounding mental illness has become more treatment-focused with direct-to-consumer advertising of psychiatric medications now a mainstay of popular media."


According to Schnittker's research, genetic arguments have, in fact, increased public support for medical treatment but at the same time aren't clearly associated with improvements in overall tolerance levels. The study explores tolerance in terms of social distancing: unwillingness to live next door to a mentally ill person, have a group home for the mentally ill in the neighborhood, spend an evening socializing with a mentally ill person, work closely with such a person on the job, make friends with someone with a mental illness or have a mentally ill person marry into the family.

When Dad Is Involved Children Of Depressed Moms Do Better, SLU Researcher Finds

Children whose mothers are depressed are less likely to develop problem behaviors if their fathers are actively engaged in family life, a Saint Louis University researcher finds.



It is well documented that children living in homes with depressed mothers are at increased risk of developing problems such as aggression, hyperactivity, depression and anxiety. However, an involved father -- one who has a positive relationship with his children -- may reduce the risk of those behaviors.



The 10-year, population-based study published in the July issue of the Archives of Pediatric and Adolescent Medicine, is the first to examine a father's role in a household with a depressed mother.



"My study corroborates findings from previous research that a child is at increased risk of problem behaviors when the mother is depressed," said Jen Jen Chang, Ph.D., assistant professor of community health in epidemiology at the Saint Louis University School of Public Health and principal investigator.



"But once we factored in a father's positive involvement, I observed that the adverse impact of the mother's depression was attenuated. The father served as a buffer. He may have engaged with the children when the mother wasn't available due to her illness."



The level of a father's involvement was based on questions given to children age 10 and older. Investigators asked the children how often their father talked over important decisions with them; whether he listened to their side of an argument; whether he knew where they were when not at home; whether their father missed events or activities that were important to them; and how close they felt to their father.



Chang's study is unprecedented not only because it examined a father's role in a household with a depressed mother but because it followed the children with multiple assessments throughout childhood and adolescence in a continuous context.



Her results drew on data from the National Longitudinal Survey of Youth (NLSY), an ongoing government-funded study of ethnically and economically diverse men and women and their labor market experiences. The NLSY contains detailed information about the biological children of these men and women, including each child's behavioral and social functioning. Chang's sample included 6,552 mother/child pairs. Child behavior problems were assessed every two years.



Chang said results of her study have important implications for intervention.



"I would advocate for health professionals to educate parents, specifically fathers, to be more involved with their children when their wives are diagnosed with depression. Mothers play an important role in a child's life. When she's mentally ill, the child is going to have difficulty, the whole family suffers. Fathers are in a position to negate that but may need a health professional's guidance."



Chang said her study was inspired by her family experience. Her sister suffered from mental illness and Chang witnessed how difficult the illness was on her sister, her family and her sister's family.



"My research has become a personal quest and I hope it will bring more focus to the issue of maternal depression," she said. "Health care professionals must do a better job of screening for this debilitating and under-diagnosed illness."



Chang next plans to study the effect of a mother's depression on a child's risk of substance abuse and whether a father's positive involvement in a child's life may reduce this risk.






Saint Louis University School of Public Health is one of only 38 fully accredited schools of public health in the United States and the nation's only School of Public Health sponsored by a Jesuit university. It offers master's degrees and doctoral programs in six public health disciplines and a number of joint degrees involving business, law, medicine, nursing and social work. It is home to 12 nationally recognized research centers and draws students from across the United States and from 21 foreign countries.

Early Menstruation Linked To Increased Risk Of Depressive Symptoms

Girls who begin menstruating at an early age are at greater risk of depressive symptoms in adolescence, according to new research published in the January issue of the British Journal of Psychiatry.



Researchers from the University of Bristol and the University of Cambridge examined the link between timing of first period and depressive symptoms in a sample of 2,184 girls taking part in a long-term study known as the Avon Longitudinal Study of Parents and Children.



The researchers used a structural equation model to examine the association between onset of menstruation and depressive symptoms at ages 10.5, 13 and 14 years.



The mean age at which the girls in the study group started menstruating was 12 years and 6 months. They found that girls who started their periods early (before the age of 11.5 years) had the highest levels of depressive symptoms at ages 13 and 14. Girls who started their periods later (after the age of 13.5 years) had the lowest levels of depressive symptoms.



Lead researcher Dr Carol Joinson said: "Our study found that girls who mature early are more vulnerable to developing depressive symptoms by the time they reach their mid-teens. This suggests that later maturation may be protective against psychological distress.



"The transition into puberty is a critical developmental period, associated with many biological, cognitive and social changes. These can include increased conflict with parents, the development of romantic relationships, changes in body image and fluctuating hormone levels. These changes may have a more negative impact on girls who mature at an early age than those who mature later. Early maturing girls may feel isolated, and faced with demands which they are not emotionally prepared for."



Dr Joinson concluded: "If girls who reach puberty early are at greater risk of psychological problems in adolescence, it may be possible to help them with school- and family-based programmes aimed at early intervention and prevention."



However, it is still unclear from this study whether early menstruation is associated with persistent adverse consequences for emotional development beyond mid-adolescence. The researchers point out it is possible that girls who mature later may eventually experience similar levels of psychological distress to those who mature earlier, after sufficient time has unfolded.



The research was funded by the Economic and Social Research Council.



References:


Joinson C, Heron J, Lewis G, Croudace T and Araya R. Timing of menarche and depressive symptoms in adolescent girls from a UK cohort. British Journal of Psychiatry 2011; 198:17-23

House Energy And Commerce Committee Approves Bill To Study Causes, Treatment Of Postpartum Depression

The House Energy and Commerce Committee on Thursday approved by voice vote a bill (HR 20) that would authorize $3 million in grants in fiscal year 2008 to study the causes and treatments of postpartum depression and postpartum psychosis, CQ HealthBeat reports (Armstrong, CQ HealthBeat, 9/27).

The bill, sponsored by Rep. Bobby Rush (D-Ill.), also would provide grants through HHS for the "establishment, operation and coordination of effective and cost-efficient systems for the delivery of essential services" for women with the conditions and their families. The measure initially would have directed NIH to conduct research on postpartum depression and postpartum psychosis, but a House subcommittee in July approved an amendment that changed "directed" to "encouraged." The bill would authorize "such sums as necessary" to continue the research for FY 2009 and FY 2010 (Kaiser Daily Women's Health Policy Report, 7/20).

According to a CDC study, about 18% of women experience depression after giving birth. No amendments were offered on the bill, CQ HealthBeat reports (CQ HealthBeat, 9/27).

Reprinted with kind permission from kaisernetwork. You can view the entire Kaiser Daily Health Policy Report, search the archives, or sign up for email delivery at kaisernetwork/dailyreports/healthpolicy. The Kaiser Daily Health Policy Report is published for kaisernetwork, a free service of The Henry J. Kaiser Family Foundation© 2005 Advisory Board Company and Kaiser Family Foundation. All rights reserved.

First Study Of Resiliency On The Battlefield Led By MSU

In the first combat-zone study of its kind, a research team led by Michigan State University found that soldiers with a positive outlook in the most traumatic situations were less likely to suffer health problems such as anxiety and depression.



The study, which surveyed Army troops fighting in Iraq, could have implications for police officers, firefighters and others who regularly deal with traumatic events such as death. Training these first-responders to think in less catastrophic terms could help them better cope with distressing events and function more effectively in the long term, said MSU's John Schaubroeck, lead researcher on the project.



The study will be published in the January issue of the Journal of Occupational Health Psychology.



"There is evidence that if we can train people to be more psychologically resilient -that is, less catastrophic in their thinking and more optimistic and more hopeful - then they function better when they encounter traumatic situations," said Schaubroeck, John A. Hannah Distinguished Professor of psychology and management. "They may be less likely to experience symptoms of post traumatic stress disorder down the line, although we don't know that for sure."



Schaubroeck added that people who have high levels of resiliency still experience stress and symptoms of health problems. "It's just that resiliency means they get over the event relatively quickly, while a low-resiliency person might have a hard time letting go."



The study was based on a survey of 648 soldiers in nine combat units fighting in Iraq in 2004. This was about 15 months after the end of major combat operations were declared, but during a period of heavy fighting against insurgents in particular areas. The information was collected in Iraq by Lt. Col. Everett Spain, an Army officer and then instructor and assistant professor at the United States Military Academy.



Many researchers have studied the psychological effects of combat after the fact, but this appears to be the first study to scientifically investigate resilience during wartime. The study analyzed traits including hopefulness, optimism and ego resilience, which basically means how well a person maintains psychological well-being during difficult times.



According to the study, the more stressful the combat situation, the more important the resiliency traits became. "Resiliency really shows itself when the chips are down," Schaubroeck said. "This is different than the way we often think about it. We often think about resiliency as having the same level of effects regardless of the level of stress."



On a practical note, Schaubroeck said leaders can play a crucial role in shaping a message of hope and optimism. It's especially important to target individuals experiencing trauma for the first time. If a rookie police officer witnesses a colleague get killed, for example, the officer needs to understand that an emotionally-charged reaction is normal, Schaubroeck said.



"The fact that you're crying because you saw someone get shot and you can't help them - it's not unusual to be in that situation if you are a police officer," Schaubroeck said. "Leaders need to be sensitive to this when debriefing people and not depend entirely on health professionals. Oftentimes when you bring in health professionals, it's too late; the psychological situation has already gotten out of hand for the individual."



Schaubroeck's co-researchers include Ann Chunyan Peng from MSU and Laura Riolli from California State University-Sacramento

Study Links Attempted Suicide With Genetic Evidence Identified In Previous Suicide Research

A Johns Hopkins-led study has found evidence that a genetic tendency toward suicide has been linked to a particular area of the genome on chromosome 2 that has been implicated in two additional recent studies of attempted suicide.


"We're hoping our findings will eventually lead to tests that can identify those at high risk for attempting suicide," says Virginia Willour, Ph.D., an assistant professor in the Department of Psychiatry at the Johns Hopkins University School of Medicine and lead author of the study. An estimated 4.6 percent of Americans ages 15 to 54 have tried to take their lives, according to Willour.


The investigators conducted a family linkage study in which they searched for commonalities in the genomes of family members with bipolar disorder and a history of attempted suicide. The same gene region on chromosome 2 that was identified by this bipolar disorder and attempted suicide study was recently identified by two complementary family studies that looked at attempted suicide in families with major depression and alcohol dependence.


"Family linkage studies are not always consistent, so the fact that all three studies, including ours, point to the same region of the genome is a good indication that we are on the right track toward identifying a gene or genes that play a role in why a person chooses to take his or her own life," says Willour.


In the multi-institutional study, results of which appear in the March issue of Biological Psychiatry, the researchers examined data from 162 families with bipolar disorder. They looked at attempted suicide in this sample because it is an important clinical problem that tends to occur more often in some of these families than in others, suggesting a distinctive genetic basis, according to senior author James B. Potash, M.D., M.P.H., of the Department of Psychiatry at Hopkins. This technique, of looking at sub-types of illness, is used by genetic researchers as a way to reduce genetic complexity.


From the 162 families, the researchers selected 417 subjects who were diagnosed with schizoaffective/bipolar disorder, bipolar I disorder or bipolar II disorder.


These subjects were asked whether they had ever attempted suicide and the degree of intent of the most serious attempt. One hundred fifty-four subjects said they had attempted suicide, and 122 stated that they had "definite" intent. For the purpose of this study, the latter were considered to have a history of attempted suicide.


Data for all 417 subjects was entered into a computer program that looks for genetic similarities between subjects with similar psychological profiles. Results indicated that family members with a history of attempted suicide and bipolar disorder showed a high degree of genetic similarity at a specific area DNA marker D2S1777 on a section of chromosome 2 referred to as 2p12. This is the same marker implicated in a 2004 study from the University of Pittsburgh School of Medicine that looked at attempted suicide and major depression. And it is close to another marker, D2S1790, located in the 2p11 region of chromosome 2, which was identified in a 2004 study from the University of Connecticut School of Medicine that looked at alcoholism and attempted suicide.















Willour says that although the Hopkins-led study does not pinpoint a specific gene responsible for attempted suicide, it does suggest a "neighborhood" in which the gene might be found. She adds that the next step is to further narrow the search and find the "address." "Once we have located the specific gene," she says, "we can better identify people who might be at risk of suicide and offer drug companies a target for possible therapies."


The data used by Willour and her team DNA samples, medical histories and psychiatric evaluations came from an independent study, CHIP, conducted at the University of Chicago, Johns Hopkins, and the National Institute of Mental Health (NIMH) Intramural Program. The purpose of CHIP, initiated in 1988 and funded through at least 2010, is to find genes that predispose people to developing bipolar disorder or particular subtypes of the illness.


Other Johns Hopkins researchers who contributed to this study are Peter P. Zandi, Ph.D., from the Department of Mental Health in the Bloomberg School of Public Health and J. Raymond DePaulo Jr., M.D.; Dean F. MacKinnon, M.D.; and Francis M. Mondimore, M.D., from the Department of Psychiatry and Behavioral Sciences. Additional researchers include Elliot S. Gershon, M.D., and Judith A. Badner, M.D., Ph.D., from the Department of Psychiatry at the University of Chicago; Francis J. McMahon, M.D., from the NIMH Intramural Program; and Melvin G. McInnis, M.D., from the Department of Psychiatry at the University of Michigan, Ann Arbor.


Funding for this study came from the National Institute of Mental Health.


Johns Hopkins Medical Institutions

901 S. Bond St., Ste 550

Baltimore, MD 21231

United States

hopkinsmedicine/

New Research Collaborations For Health Announced Between NHS Organisations And Leading Universities, UK

Two new partnerships between NHS organisations and leading
universities will receive a total of ??18 million to conduct research
and improve care in major conditions including depression, dementia,
stroke, and childhood obesity, the Department of Health announced
recently.



The new NIHR (National Institute for Health Research) Collaborations
for Health Research and Care in Nottinghamshire and in Cambridgeshire
& Peterborough were selected by an independent international
selection panel and will start work on 1st October 2008.



The two new partnerships will complement the seven Collaborations
announced in May 2008, which will also start work in October. Each
Collaboration will bring together universities and their surrounding
NHS organisations to test new treatments and new ways of working in
specific clinical areas, to see if they are effective and appropriate
for everyday use in the health service. Where potential improvements
are identified, the collaborations will help NHS staff to incorporate
them into their everyday working practices, so that patients across
the local community receive a better standard of healthcare.



Professor Sally C. Davies, Director General of Research and
Development at the Department of Health said:



"The NIHR Collaborations for Health Research and Care represent an
exciting and innovative partnership between universities and the NHS.
They will undertake high quality applied health research and develop
new ways of translating research findings into improved outcomes for
patients. They will be conducting this work at the front line of the
NHS so that the benefits and findings from research can be swiftly
incorporated into routine clinical practice."



1. The NIHR Collaborations for Leadership in Applied Health Research
and Care (NIHR CLAHRCs) will undertake high-quality applied health
research focused on the needs of patients and support the translation
of research evidence into practice in the NHS for the benefit of
patients, including the trialling and evaluation of initiatives to
encourage adoption of evidence based practice or clinical
effectiveness. Further information about NIHR CLAHRCs (including
details of the seven CLAHRCs announced on 27th May) is available at:
nihr.ac.uk/infrastructure_clahrcs.aspx.



2. List of new NIHR CLAHRC awards and areas of activity:



Name of Collaboration

NIHR CLAHRC for Nottinghamshire
















Lead NHS Organisation

Nottinghamshire Healthcare NHS Trust



Academic Partner(s)

University of Nottingham



Themes


- Multi-level assessment and intervention to implement innovation in
the delivery of patient-focused care in NHS Trusts


- Synthesis and dissemination of research and implementation
programme: engaging stakeholders through a focus on access to care
and occupational outcomes


- An organisational studies approach to commissioning and
implementing innovation for local service delivery to people with
serious mental illness and personality disorder


- Targeting behavioural interventions for people with challenging
chronic illness in primary care: Reducing the burden of disability
and improving service effectiveness


- Translating stroke rehabilitation into NHS clinical practice


- Children and Young People's Health and Behaviour: Putting evidence
into practice



Name of Collaboration

NIHR CLAHRC for Cambridgeshire & Peterborough



Lead NHS Organisation

Cambridgeshire & Peterborough Mental Health Partnership NHS Trust



Academic Partner(s)

University of Cambridge



Themes

- Addressing the mental health and wellbeing of adolescents with
ongoing mental health and social care needs


- Mental health and psychological wellbeing among adults with
long-term conditions: maintaining and improving the lives of people
with developmental conditions or post-traumatic impairments of brain
function


- Supporting mental health in the older population


- Public Health supporting mental health across the lifespan


- Designing High Quality Care Pathways




3. To be successful, the NHS/University partnerships had to
demonstrate an excellent record in undertaking applied health
research (particularly research targeted at chronic disease and ways
of improving public health) and to put forward very strong proposals
for new research and for implementing research findings, which were
very likely to generate a step change in the way that research is
done and research evidence is implemented into practice.



4. The research to be undertaken by the two new NIHR CLAHRCs will aim
to improve diagnosis and/or treatment and ensure that improved ways
of working are introduced into the NHS in the following areas:



- the transition of adolescents with ongoing mental health and social
care needs from services for young people into adult mental health
services and the community



- support for men and women with long-term conditions, such as
learning disabilities, autism spectrum disorders and cerebral palsy



- the mental health of the older population, including studies of
dementia and depression



- serious mental illness & personality disorder



- stroke rehabilitation



- childhood obesity



- Attention Deficit/Hyperactivity Disorder (ADHD),



- enhancing prevention and service access for disadvantaged South
Asian communities in relation to obesity and diabetes, and depression
& anxiety



5. Funding for all nine CLAHRCs will commence on 1st October 2008 and
will total ??88 million over five years.



6. The National Institute for Health Research provides the framework
through which the research staff and research infrastructure of the
NHS in England is positioned, maintained and managed as a national
research facility. The NIHR provides the NHS with the support and
infrastructure it needs to conduct first-class research funded by the
Government and its partners alongside high-quality patient care,
education and training. Its aim is to support outstanding
individuals (both leaders and collaborators), working in world class
facilities (both NHS and university), conducting leading edge
research focused on the needs of patients. More information about the
National Institute for Health Research is available on its website
at: nihr.ac.uk.



7. The National Institute for Health Research's progress report
"Transforming Health Research the first two years" can be downloaded
from the NIHR website at:
nihr.ac.uk/about_progress_report.aspx.

National Institute for Health Research

Depression and fatigue not associated with cancer risk, Study finds

Feeling depressed and fatigued does not increase a person's risk for cancer, according to a new study. Severely exhausted people, however, do engage in behavior that is associated with a higher cancer risk.

The study, published in the September 15, 2005 issue of CANCER (interscience.wiley/cancer-newsroom), a peer-reviewed journal of the American Cancer Society, is the first prospective study using the "vital exhaustion" questionnaire to investigate this link.


The concept of vital exhaustion - described as feelings of excessive fatigue and lack of energy, increased irritability and a feeling of demoralization - grew out of the field of cardiology. Studies have identified vital exhaustion as a risk factor for heart attacks and death from a heart attack.


Depressive mood has also been widely blamed, at least in lay literature, as a risk factor for cancer. However, the scientific data is much more inconsistent than that for heart attacks. Two recent prospective studies failed to identify a link between depression and cancer.


Corinna Bergelt, Ph.D. of the Danish Cancer Society's Institute of Cancer Epidemiology in Copenhagen and colleagues followed 8527 people aged 21-94 years to investigate whether depressive feelings and exhaustion were risk factors for cancer, looking at all cancers combined, smoking-related cancers, alcohol-related cancers, virus and immune-related cancers, and hormone-related cancers.


The researchers did find people with high vital exhaustion scores engaged in behaviors that put them at higher cancer risk, such as tobacco consumption and low physical activity. Depite that, they found no association between the severity of vital exhaustion and an increased cancer risk. In fact, the authors actually found those at the highest end of the vital exhaustion score had a slightly decreased risk for cancer at all sites, virus and immune-related cancers, and smoking-related cancers. No significant associations were found between vital exhaustion and hormone- and alcohol-related cancers.


The authors conclude: "The results of this large, prospective, population-based study do not support the hypothesis that subclinical depressive feelings, as measured by the vital exhaustion questionnaire, increase the risk for developing cancer."


Article: "Vital Exhaustion and Risk for Cancer: A Prospective Cohort Study on the Association between Depressive Feelings, Fatigue and Risk for Cancer," Corinna Bergelt, Jane Christensen, Eva Prescott, Morten Gr?nb?k, Uwe Koch, Christoffer Johansen, CANCER; Published Online: August 8, 2005 (DOI: 10.1002/cncr.21302); Print Issue Date: September 15, 2005.


John Wiley & Sons, Inc.

interscience.wiley

New Therapy Gives Hope For Very Severe Depression

Thanks to a new method there is a reason for hope for patients with very severe depression. Physicians at the University Clinics of Bonn and Cologne have treated ten patients with deep brain stimulation. This involved implanting electrodes in the patients' nucleus accumbens. This centre has a key role as the brains reward system, whose function may be impaired in depressive people. Subsequent to this treatment, the patients' depression improved significantly in half of the patients. All patients had suffered from very severe depression for many years and did not respond to any other therapies. The results of the study will be published in the journal Biological Psychiatry (doi: 10.1016/j.biopsych.2009.09.013).



In deep brain stimulation, doctors specifically target the impaired function of certain areas of the brain with an electric brain pacemaker. For the purpose of this study, they implanted electrodes in what is known as the nucleus accumbens. That is an important part of the 'reward system' which ensures that we remember good experiences and puts us in a state of pleasant anticipation. Without a reward system we would not forge any plans for the future as we would not be able to enjoy the fruits of these plans. Inactivity and the inability to experience pleasure are two important signs of depression.



A total of ten patients with very severe depression participated in the study. In all patients, symptoms did not improve despite many therapies using psychotherapy or pharmacotherapy. Overall, all participants showed signy of improvement, in half of them symptoms of depression improved significantly. Initial effects could sometimes be seen just after a few days. 'Thus, inter alia we observed increasing activity of the patients,' Professor Thomas E. Schlaepfer from the Bonn Clinic of Psychiatry and Psychotherapy explains. 'This was so successful that some of them were even able to work again, after having been incapacitated for many years. None of our patients had ever responded to any other therapy to a comparable extent before.'



Hardly any side effects



Five patients' well-being improved considerably and in a sustained fashion. Even after a year, the stimulation of the nucleus accumbens still had the same efficacy as at the beginning of the study. During the study, the scientists also observed distinct anxiety-relieving effects which had not been observed in studies on deep brain stimulation to date. 'Severe anxiety is often an accompanying effect of depression,' the primary author of the study Dr. Bettina Bevernick explains. The overall brain function of the participants was not impaired by the treatment, some neurophysiological functions even improved. Overall, the scientists only noticed minor side effects, e.g. as a consequence of the operation or after changing the electrical parameters of stimulation. However, these effects always wore off after short periods of time.



Stimulation changes the brain metabolism



But what is the exact effect of the stimulation of the nucleus accumbens? 'We were able to show using functional brain imaging methods that the stimulation changes metabolic rates of different areas of the brain,' Thomas Schlaepfer says. 'What is very important is that the metabolic changes do not just affect the nucleus accumbens itself but also other regions of the limbic system, where the brain processes emotions and that are known to be dysfunctional in depression.



Due to the small number of patients in this and similar studies, the scientists warn against exaggerated hopes. Moreover, with brain surgery in psychiatric patients specific ethical issues have to be considered very carefully, not least because such an operation is always associated with risk. 'However, our study definitely shows that deep brain stimulation can help some patients with extremely severe forms of depression,' Thomas Schlaepfer stresses. 'That even goes for cases which were thought to be absolutely therapy-resistant up to now.'

UCLA: With Futures So Bright, New College Students Are Depressed Over Finances

Students entering college are more depressed, timid and stressed about finance as they enter the higher education ranks according to information released this week by UCLA's annual survey of the nation's entering students at four-year colleges and universities.



Half of students reported a 3.4% downturn in their emotional health compared to 2009's similar analysis. As this information is self-reported, 46% of female students were far less likely to report high levels of emotional health than the 59% of males. Women were also more than twice as likely as men to feel frequently overwhelmed as high-school seniors.



Sylvia Hurtado, co-author of the report and director of the Higher Education Research Institute explains:


"The increasing cost of higher education poses a significant barrier to college access for today's students. Students and families are now charged with the task of becoming more resourceful and strategic in finding new and creative ways to pay for college."


The proportion of students using loans is 53%, and 74% of students are reporting receiving grants and scholarships. This is an increase of 3.5% since a year before, 2009.


John H. Pryor, lead author of the report and director of the Cooperative Institutional Research Program continues:


"Stress is a major concern when dealing with college students. If students are arriving in college already overwhelmed and with lower reserves of emotional health, faculty, deans and administrators should expect to see more consequences of stress, such as higher levels of poor judgment around time management, alcohol consumption and academic motivation. The chief benefit of college is that it increases one's earning power."



However there is an upside. Obviously students' perceived emotional health took a dip, but their drive to achieve and their academic abilities are better these days. Seventy one percent of students feel their academic talents are excellent and they plan on "winning" in the academic game. In UCLA's report, high levels of drive to achieve and academic ability could also contribute to students' feelings of stress.



The percentage of students reporting that their fathers were unemployed, five percent, is at an all-time high. Students additionally reported that 8.5% of their mothers were unemployed. These facts, at the core level, stress new students out and they feel more pressure and responsibility to exceed.


Carol Schneider, president of the Association of American Colleges and Universities is positive however as new students are more liberal although the cloud of heavy monetary debt lingers:


"I am heartened to learn about students' overwhelming support for extending equal rights and dignity to gays and lesbians. Students' willingness to engage different perspectives and experiences is a virtual precondition for their own intellectual development in college and one of higher education's most important contributions to the future of a just and diverse democracy."

Risk For Heart Disease Elevated By Combined Hostility And Depression

Researchers led by Jesse Stewart, Ph.D., assistant professor of psychology at Indiana University-Purdue University Indianapolis, report that hostility and depression appear to act together in a complex way to elevate inflammatory proteins in the human body, possibly putting hostility plus depression on the list of risk factors for heart disease along with high blood pressure, elevated cholesterol, and smoking.



The findings, that hostility enhances inflammatory processes relevant to heart disease only in the presence of depressive symptoms, are published in the February-March 2008 issue of Psychosomatic Medicine. Dr. Stewart and colleagues examined associations of depressive symptoms and hostility with blood levels of two inflammatory proteins, interleukin-6 and C-reactive protein, that are predictive of future heart disease. Participants in the study were 316 healthy men and women aged 50-70.



Previous studies have found depression to be associated with raised inflammatory protein levels. Other studies have confirmed links between hostility and inflammatory proteins that are predictive of heart disease. But this study is the first to find that, among older adults, the relationship between hostility and these inflammatory proteins depends on the level of depression.



"In our study, we looked at depression and hostility simultaneously, and we found that the relationship of these negative emotions to inflammatory markers is more complex and much stronger than depression or hostility individually," said Dr. Stewart, who notes that depression and hostility tend to co-occur within individuals.



Psychological risk factors for heart disease merit further study. According to Dr. Stewart, the strength of the association of psychological factors with future heart disease is similar to that of traditional risk factors like smoking, high blood pressure, and elevated cholesterol.



"There are of course mental health reasons to treat depression and hostility. Now we know there is a physical health reason - the link to cardiovascular diseases," said Dr. Stewart, a clinical health psychologist at IUPUI's School of Science, is an IU Center for Aging Research affiliated scientist.







Co-authors of the National Heart Lung and Blood Institute funded study, in addition to first author Dr. Stewart, are Denise Janicki-Deverts, Ph.D. of Carnegie Mellon University; Matthew Muldoon, M.D., M.P.H. and Thomas Kamarck, Ph.D. of the University of Pittsburgh.

Serotonin Receptor: A Rheostat In Brain For Emotion That May Be Linked To Depression

Although drugs that target the brain's serotonin system are widely used to treat depression, the basic biological mechanism by which they help to alleviate symptoms is poorly understood. Now, new University of Pittsburgh research suggests these drugs work by acting on a specific serotonin receptor called the 5-HT1A autoreceptor, which the study's investigators found plays a key role in regulating the response of the amygdala.



The findings, published in the journal Nature Neuroscience, also provide a model of how specific changes in 5-HT1A autoreceptors and associated amygdala reactivity may impact a person's risk for developing depression. Much like a rheostat, these serotonin receptors regulate the brain's emotional responses and may contribute to one's vulnerability for depression and other psychiatric disorders.



The amygdala is a critical component of brain circuitry that processes clues from the environment about potential threats and generates appropriate behavioral and physiological responses - such as the "fight or flight" response - to these challenges. Research has indicated that depression and other mood disorders, such as anxiety, are associated with emotional brain circuitry problems involving the amygdala.



The 5-HT1A autoreceptor is located on the surface of serotonin neurons, which are responsible for producing the serotonin neurotransmitter and delivering it to several areas of the brain, including the amygdala. The effect serotonin release has is varied and complex, due to the number of different serotonin receptors found in these brain regions. In contrast, the 5-HT1A autoreceptor on serotonin neurons in the brain stem is rather uniform: it reduces the neuron's activity and its subsequent release of serotonin to downstream targets, a process called negative feedback inhibition. As more serotonin is released and becomes available in the brain, the neurotransmitter also acts on these 5-HT1A autoreceptors, which in turn work to reduce serotonin release.



In brain imaging studies of 20 normal subjects, the team of investigators found that individuals who had higher concentrations of the 5-HT1A autoreceptor, as assessed by positron emission tomography (PET), also had significantly reduced activity in their amygdala, which was measured by functional magnetic resonance imaging (fMRI). Moreover, the concentration of the 5-HT1A autoreceptor accounted for 30 to 44 percent of the differences in the reactivity of the amygdala among individuals.



"There's a significant inverse relationship between the density of the 5-HT1A autoreceptor and the amygdala's reactivity to threatening stimuli, and this mechanism appears to be reflecting the effects of the 5-HT1A on the negative feedback loop that controls the release of serotonin," said study leader Ahmad R. Hariri, Ph.D., assistant professor of psychiatry and director of the Developmental Imaging Genetics Program at the University of Pittsburgh School of Medicine and Western Psychiatric Institute and Clinic.
















"This observation could be important in understanding a key molecular pathway that may make some people more vulnerable for developing depression or other psychiatric disorders. In our normal subjects, we saw a pattern that suggests the reactivity of the amygdala is regulated by the capacity for negative feedback regulation of serotonin release through the 5-HT1A autoreceptor. Moreover, the pattern suggests that higher levels of serotonin, associated with reduced autoreceptor density and negative feedback, is linked with greater amygdala reactivity," he added.



The study is one of the few to collect data in research subjects using these two different imaging methods, allowing for more complete interpretations to be drawn about the relationship between molecular changes in the brain and differences in behavior.



In earlier studies, Dr. Hariri and colleagues established a brain basis for a gene variant and its relationship to behavior, finding greater amygdala reactivity in people carrying a form of a gene that leads to reduced expression of the serotonin transporter, who, because of this variation, are more vulnerable to developing depression in the face of stressful and difficult life circumstances. Recently, other researchers have noted that this same genetic variation is associated with reduced 5-HT1A density. Moreover, alterations in 5-HT1A autoreceptor density and amygdala reactivity have been documented in depression, and studies suggest that the class of drugs known as selective serotonin reuptake inhibitors (SSRIs) may evoke an antidepressant effect by acting on both the 5-HT1A autoreceptor and amygdala reactivity. Taken together, Dr. Hariri's latest findings may be important for understanding the molecular mechanisms underlying the effects of the serotonin transporter gene variation on amygdala reactivity.



"Antidepressants, especially the SSRIs, which increase the availability of serotonin, may actually be working by shifting the availability of 5-HT1A autoreceptors and, as a consequence, modulating the reactivity of the amygdala. Such shifts may drive the improvements in depressed mood and affect that result from SSRI treatment," explained Dr. Hariri, who plans to conduct additional studies in both healthy volunteers and patients with depression in order to better understand the specific biological pathways that contribute to risk for the condition as well as predict treatment response.







Others who contributed to this research include Patrick M. Fisher, Scott K. Ziolko, Julie C. Price, Ph.D., of the University of Pittsburgh School of Medicine; and Carolyn C. Meltzer, M.D., now at Emory University.



The research was supported by the National Institute of Mental Health of the National Institutes of Health and the National Alliance for Research on Schizophrenia and Depression.



Contact: Lisa Rossi


University of Pittsburgh Medical Center

Suicide Rates: Lowest In 30 Years, Not Affected By Reducing Antidepressant Prescriptions

Two studies related to suicide performed by researchers from the
University of Bristol report that 1) suicide rates in young men are at
their lowest levels in 30 years and 2) the reduction in prescribing of
antidepressants to people under the age of 18 does not seem to be
associated with change in suicidal behavior in young people. Both
papers are published online at bmj.



Authors of the first paper analyzed men and women aged 15-34 years in
England and Wales between 1968 and 2005. The time trend analysis
included data on mortality, population statistics and surveys,
prescription information, and data on unemployment and
divorce. The main finding was that fewer young men in England
and Wales are dying by suicide than at any time in the last 30 years.



Specifically, the researchers report that:


For 15-24 year-old men, the overall suicide rate dropped
from 16.6 per 100,000 people in 1990 to 8.5 per 100,000 in
2005.
For 25-34 year old men, overall suicide rates declined from
22.2 per 100,000 in 1990 to 15.7 per 100,000 in 2005.

A reduction in unemployment and laws that have reduced the risks from
car exhaust fumes are cited as contributory factors. The increased
number of cars with catalytic converters - due to emissions legislation
from 1993 - has led to a sharp reduction in exhaust gas poisoning; this
has contributed to the falling suicide rates. However, there are
several factors, including the suicide prevention policy initiatives in
England and Wales, which have played a role in the decline.



The results for women are slightly different. Female suicide rates in
the 21st century are at their lowest levels since 1968, but there has
been a dramatic increase in the proportion of women aged 15-34 who
commit suicide by hanging - 5.7% of all suicides in 1968 to 47.3% in
2005.



Co-author David Gunnell reports, "Favorable changes in several
different factors - levels of employment, substance misuse and
antidepressant prescribing as well as policy focus on suicide and
vehicle exhaust gas legislation - may have contributed to the recent
reductions."



In the second study, researchers analyzed three separate sets of data
between 1993 and 2006: 1) Selective serotonin reuptake inhibitors
(SSRI) antidepressant prescriptions to 12-19 year olds in the UK, 2)
annual deaths from suicide in 12-17 year olds in England and Wales, and
3) hospital admissions for self-harm in 12-17 year olds in England.



The main finding is that the recent restrictions prescribing
antidepressants to children and adolescents in the UK has had no effect
on suicide rates.



Although the regulatory restrictions led to a halving of antidepressant
prescriptions, the study authors found no evidence of a temporal
association between trends in antidepressant prescribing and deaths
from suicide or hospital admissions for self harm.



"These findings are important because they suggest that reduced access
to antidepressants in young people appears not to have had an adverse
impact on suicide deaths," conclude the authors.



In an editorial accompanying both articles, Gregory Simon argues that
that sustained use of antidepressants is probably too infrequent to
have much of an overall effect on the risk of suicide in people living
with depression. "Clinical
trials cannot determine whether antidepressants increase or decrease
the risk
of genuine suicide attempts or death from suicide because these
outcomes are,
fortunately, too rare. No deaths from suicide and few attempts at
suicide have
occurred to date in trials of antidepressants in adolescents."



Suicide rates in young men in England and Wales in the 21st
century: time trend study

Lucy Biddle, Anita Brock, Sara T Brookes, David Gunnell

BMJ. (February 14, 2008)

doi:10.1136/bmj.39475.603935.25

Click
Here to View Article



The population impact on incidence of suicide and non-fatal
self harm of regulatory action against the use of selective serotonin
reuptake inhibitors in under 18s in the United Kingdom: ecological study

Benedict W Wheeler, David Gunnell, Chris Metcalfe, Peter
Stephens, Richard M Martin

BMJ. (February 14, 2008)

doi:10.1136/bmj.39462.375613.BE

Click
Here to View Article



Written by: Peter M Crosta

Neighborhoods Can Have Depressing Effect On Health, According To Iowa State Study

The nation's poverty rate climbed to 14.3 percent -- the highest level since 1994 -- according to the Census Bureau's annual report on the economic well-being of U.S. households. That means one in seven Americans now live in poverty, and that may have an especially depressing effect on people living in bad neighborhoods, according to two Iowa State University researchers.



Daniel Russell, an Iowa State professor of human development and family studies; and Carolyn Cutrona, professor and chair of psychology, presented "Stressful Effects of Where You Live: Studying the Influence of Neighborhood Context Over Time," in August at the World Conference on Stress and Anxiety Research in Galway, Ireland. Their presentation summarized data taken from the Family and Community Health Study (FACHS), an ongoing ISU study of 800 African American families -- approximately half living in Iowa and half in Georgia -- that started in 1997.



Russell and Cutrona reported that negative neighborhood infrastructure can keep neighbors from forming social ties. And it's the absence of those social ties that have a small but significant impact on an individual's mental health.



"If you're living in neighborhoods where there's a lot of crime, gang activities and so forth, you see weaker social ties," said Russell, a noted loneliness researcher. "One of the things we tried to assess was essentially community support -- to what extent people in that neighborhood turned to others for child care, other forms of assistance -- and whether they socialize and know each other. And it's clear that in these negative neighborhoods there's this inverse relationship in terms of their various problems and lack of strong ties."



The compounding effect of bad neighborhoods



In neighborhoods where social disorder -- or a lack of social ties -- was perceived to be high, the effects on the subjects' perceived personal risk were amplified. The effects of personal risk were muted in neighborhoods with low social disorder.



"The effects of things going wrong in your own life are magnified when you live in one of these negative neighborhoods," said Cutrona, who presented related research this month to staff members for Iowa Sen. Tom Harkin. "So it affects all of us to have a sick family member, or lose our job, or to be robbed. But when that happens to someone in these neighborhoods, it increases the probability that the person will be diagnosed with a major depressive disorder over the next two years. Yet if the same event happened and you were in a more benign neighborhood, your chances of becoming clinically depressed were less."



Sixty-two percent of the study's participants subsequently moved to different neighborhoods between 1997 and 2005, with the rate of moving from specific neighborhoods ranging from 22 to 90 percent. "Neighborhood cohesion" was identified by subjects as the most desirable characteristic of their new neighborhoods. And people who lived in cohesive neighborhoods were much less likely to move away.
















But the ISU researchers found that the lack of racism was the only factor that significantly improved depression among the African American subjects after they moved.



"If the new neighborhood was less racist overall -- not just their perception, but the perception of multiple people who lived in that neighborhood -- then the subjects' moods improved following that move," Cutrona said. "So it was not about moving to a wealthier neighborhood, or even a safer neighborhood, but moving to a less racist neighborhood that impacted depression levels."



Not only representing low income families



The researchers emphasize that the study's sample does not solely reflect perceptions of low income families. Only about 20 percent of the families surveyed were below the poverty line and the sample included a wide range of family incomes, including some families that earned more than $200,000 per year.



"When we started the study, the average income of this study matched the average income of Iowans," Russell said.



But both Cutrona and Russell agree that it is the low-income subjects living in negative neighborhoods who are most vulnerable to prolonged depression.



"If you have to live in one of these neighborhoods, you may not have the resources for health insurance and good mental health care," Cutrona said. "And you may not have the support around you to say, 'This is depression and it's treatable.'"



Russell reports he and Cutrona have received funding from the National Institute of Mental Health to collaborate with researchers at the University of Iowa and the University of Georgia to study the role of genetic factors and neighborhood environments on depression in the FACHS sample.

Surfing The Blues -- Internet Questionnaire Can Accurately Identify Depression

The Internet offers a valuable opportunity for the public to screen themselves for depression. This is the conclusion of a study published recently in BMC Psychiatry, which demonstrates that a Chinese online tool for assessing depression is both accurate and reproducible, and may offer a way to identify the growing number of people suffering from depression.



Chao-Cheng Lin of the National Taiwan University Hospital, Yu-Chuan Li of the National Yang-Ming University, and other colleagues in Taiwan developed the Internet-based Self-assessment Program for Depression (ISP-D). Between September 2001 and January 2002 the team recruited 579 subjects via a popular mental health website. Volunteers were sent a follow-up email one to two weeks after completing the first questionnaire inviting them to re-sit the test, and those who completed the questionnaires were offered a psychiatrist's appointment to validate the diagnosis.



Results of the first assessment showed that 31% of participants had major depressive disorder, 7% a minor depressive disorder, 15% had some symptoms of depression that did not amount to a full diagnosis of depression (subsyndromal depressive symptoms) and 46% had no depression. Analysis of the retest results show excellent reproducibility for major depressive disorder. The reproducibility was lower for minor depressive disorder, which may be because minor depression is not a stable diagnosis. The psychiatrist's follow-up revealed that the diagnosis was correct for ?? of those tested online.



Already between 1/5 and 2/5 of the world's population suffer from depression, but most remain undetected or go untreated, making it vital to provide more opportunities for diagnosis.



"The ISP-D provides a continuously available, inexpensive, and easily maintained depression screening method that is accessible to a large number of individuals across a broad geographic area," write the authors. This tool allows people to reliably assess depression in themselves on their own and in a short amount of time.







Article:

Web-based tools can be used reliably to detect patients with major depressive disorder and subsyndromal depressive symptoms

Chao-Cheng Lin, Ya-Mei Bai, Chia-Yih Liu, Mei-Chun Hsiao, Jen-Yeu Chen, Shih-Jen Tsai, Wen-Chen Ouyang, Chia-hsuan Wu and Yu-Chuan Li

BMC Psychiatry 2007, 7:12 (In press)



Contact: Martyn Thomas

BioMed Central

New Survey Reveals How The Credit Crunch Is Affecting Our Mental Health, UK

A new survey out today on World Mental Health Day has revealed that whilst the credit crunch has understandably made many people a little more depressed and anxious, just 8% had become a lot more depressed and anxious.


The YouGov survey commissioned by mental healthcare specialists Affinity found that overall 51% of people surveyed said that they were in fact unaffected by the current financial circumstances, and a further 37% had been a little more anxious or depressed. There were some variations in responses in that greater levels of effect were reported in those aged between 45-54 (41% a little more anxious and depressed, 9% a lot more anxious and depressed). Also the most affected regions have been Yorkshire and the Humber (46%), West Midlands and East of England (all with 47%) whilst the North East is the least, with 37%.


An issue raised through this survey was variation in how open people are in acknowledging mental health symptons. People in the North East are more likely to admit they have suffered a mental illness (24%) whilst those in the East of England and the South West are least likely to (11%).


Affinity Healthcare's consultant psychiatrist and honorary professor at Chester University Dr Ben Green said: "This is an interesting snapshot of the UK's mental health. It is clear that the credit crunch is having some effect on people's mental wellbeing, and it is clear that there is variation in how open some people are able to be about their mental health.


"Mental health is often affected by the economic climate and it's understandable that homeowners are more likely to feel more depressed and anxious due to the current economic turbulence. However, with openness and support, symptoms might well resolve."


He added that mental illness, which can be a problem with anxiety, mood or behaviour or a mental disorder, is misunderstood in the UK. The survey revealed that mental health problems affect many people's lives, either directly or through family members or close friends. Women are more likely to speak out with 17% admitting to suffering from a mental illness compared to 13% of men.


Dr Ben Green continued: "This survey is aimed at raising awareness of mental health and dispelling the negative stereotypes that people attach to the disorder. It revealed that 36% of respondents thought drug addicts would be most likely to suffer from a mental health problems, with another 19% admitting to thinking elderly people would be most likely to suffer.


"With some commentators stating that 1 in 4 of all people are likely to suffer from a mental health problem at some point in their life, we believe that these findings show that many people don't realise that it can be something as common as suffering from depression or anxiety."


Dr Green added "Another worrying area of this survey is that a high proportion of young people aged 18-24 (38%) seem to be turning to the internet as a way of diagnosing their problem rather than seeking treatment from a professional. It's vital that someone who suffers from mental health problems seeks professional clinical help in the form of a family doctor or a recognised support service.


"Mental health problems can leave individuals feeling isolated and alone. On World Mental Health Day, it's important that people realise they don't have to suffer alone and that there is help available."


For help and advice on any mental health issues contact:

MindinfoLine (Monday to Friday 9.00am - 5.00pm) on 0845 766 0163


-- YouGov polled 2,039 people across the UK between 30th September- 2nd October


-- Affinity Healthcare is a leading provider of mental health services to the NHS and operates Cheadle Royal Hospital, Cheshire and Middleton St George Hospital, Darlington


-- Affinity Healthcare has over 200 years of experience in treating the mentally ill


-- Affinity has the expertise to provide treatment that addresses mental health and the risk issues to affect positive outcomes


-- Affinity is a provider of multidisciplinary, patient-centered, high quality and cost effective treatment


-- The World Health Organisation study in 2001 found that 1 in 4 people in the world will suffer from mental illness in their lifetime


For more information on Affinity Healthcare go to affinityhealth.co.uk


For more information on Mind go to mind.uk

Why Are So Many Children Still On Antidepressants In The UK?

In 2003, the British people were told by the authorities that teenagers and children should not be given SSRI antidepressants after medical professionals were concerned that some of them became suicidal while others experienced serious mood swings. Prozac continued to be recommended, for under 18s, but only in cases of severe depression.


So, why is it that in 2004-2005 over 84,000 children in the UK are still on such drugs? Over 27,000 of those under 15.


The 2004-2005 figures were made public after the Liberal Democrats asked for it in Parliament.


According to Paul Burstow, LibDem Health Spokesperson, doctors are carrying on prescribing these drugs despite warnings by experts that they can lead to an increased risk of suicide. He added that the 'shocking over-reliance on the use of these drugs demonstrates yet again the chronic shortage of talking therapies and the weakness of the Child and Adolescent Mental Health Services. These figures should be ringing alarm bells at the Department of Health and calling into question the way in which advice on medicines is monitored.'


The UK Dept of Health says some of these medications are used for other indications such as bed-wetting, anxiety, obsessive compulsive disorder and some phobias.



Present guidelines in the UK are that the risks these drugs pose to children outweigh the benefits.







View drug information on Prozac Weekly.

Letter from MHRA to Doctors regarding antidepressants

Dear Colleague


I am writing to tell you the advice of the CSM on the safe use in adults of SSRI antidepressants in the light of CSM's Expert
Working Group Report on SSRIs and new advice in relation to the antidepressant venlafaxine (Efexor).


Background


In December 2003 the CSM issued advice on the use of SSRIs in the treatment of major depressive disorder in children. Since
then its Expert Working Group has examined a large body of safety evidence from a wide range of sources - spontaneous
suspected adverse drug reactions, clinical trials, published literature and epidemiological databases. The key findings of
the Expert Working Group are listed in Appendix 1.


Key Conclusions


SSRIs are effective medicines in the treatment of depression and anxiety conditions, and the CSM has concluded that the
balance of risks and benefits of all SSRIs in adults remains positive in their licensed indications. Clear advice is to be
given in all SSRI product information in 3 areas: withdrawal reactions, dose changes, and suicidal behaviour.


Summary of general prescribing advice


1 For the majority of SSRIs in the treatment of depressive illness, clinical trial data do not show any additional benefit
from increasing the dose above the recommended daily dose. In the absence of evidence of a benefit from increasing the dose,
good practice would be to maintain patients on the lowest efficacious dose. For patients currently on a dose above the
recommended dose, the advice is to complete the course if the patient is well.


2 Careful and frequent patient monitoring by healthcare professionals, and where appropriate other carers, is important in
the early stages of treatment, particularly if a patient experiences worsening of symptoms or if new symptoms arise after
starting treatment.


3 If a patient is not doing well after starting treatment the possibility of an adverse reaction to the drug should be
considered. Patients should be monitored for signs of restlessness or agitation, particularly at the beginning of treatment.
Increasing the dose in these circumstances may be detrimental.


4 Evidence of a relationship between suicidal behaviour and increasing/decreasing dose is not robust, however patients should
be monitored around the time of dose changes for any new symptoms or worsening of disease.


5 To minimise withdrawal reactions on stopping SSRIs, the dose should be tapered gradually over a period of several weeks,
according to the patient's need.


6 There is no clear evidence of an increased risk of self-harm and suicidal thoughts in young adults of 18 years or over. But
individuals mature at different rates and young

















adults are at a higher background risk of suicidal behaviour than older adults, so as a precautionary measure young adults
treated with SSRIs should be closely monitored.


Venlafaxine (Efexor)


The CSM has additionally considered the balance of risks and benefits of Efexor because of concerns about cardiotoxicity and
toxicity in overdose. CSM recommended that treatment with Efexor should only be initiated by specialist mental health
practitioners, including GPs with a special interest, and there should be arrangements in place for continuing supervision of
the patient.


Efexor should not be used in patients with heart disease, (e.g. cardiac failure, coronary artery disease, ECG abnormalities
including pre-existing QT prolongation), patients with electrolyte imbalance or in patients who are hypertensive.


Patients currently doing well on treatment with venlafaxine can continue to the end of their course.


NICE Guidelines


The National Institute for Clinical Excellence (NICE) has today issued guidelines for the NHS on the treatment and care of
people with depression and anxiety.


The key priorities for implementation for each guideline are set out in Appendix 2 .


Electronic copies of the quick reference guides for both depression and anxiety can be found on the NICE website at nice.uk.

Hard copies of both guidelines will be
distributed to the NHS on 15th December.


Further information


Further information for prescribers and patients including questions and answers and the full report of the CSM's Expert
Working Group Report on SSRIs is available on the website of the MHRA (mhra.uk).


Please report any suspected adverse reactions via the Yellow Card reporting scheme to the CSM/ MHRA.


Should you require any additional information, please telephone 020 7084 2000 at the MHRA.


Yours sincerely


Professor Gordon Duff



Annex 1


CSM EXPERT WORKING GROUP ON SSRIS


KEY FINDINGS


Use of in SSRIs in adults


Suicidal behaviour - adults


-- There is epidemiological evidence that the risk of self harm in depressed patients is greatest around the time of
presentation to medical services. It is general clinical experience that the risk of suicide may increase in the early stages
of treatment for depressive illness.


-- Careful and frequent patient monitoring by healthcare professionals, and where appropriate other carers, is important in
the early stages of treatment, particularly if a patient experiences worsening of symptoms or new symptoms after starting
treatment.


-- Studies indicate that increases in the prescribing of SSRIs have not been associated with an increase in population
suicide rates, although interpretation of these findings is difficult as a range of factors influence population trends in
suicide.


-- From the available clinical trial data, both published and unpublished, a modest increase in the risk of suicidal thoughts
and self-harm for SSRIs compared with placebo cannot be ruled out. There is insufficient evidence from clinical trial data to
conclude that there is any marked difference between members of the class of SSRIs, or between SSRIs and other
antidepressants with respect to their influence on suicidal behaviour.


-- Evidence from non-experimental studies based on the General Practice Research Database indicates that there is no
increased risk of suicidal behaviour with SSRIs compared with TCAs.


-- There is no clear evidence that there is an increased risk of self-harm or suicidal thoughts when SSRIs are discontinued.



-- Evidence of a relationship between suicidal behaviour and increasing/decreasing dose is not robust, however patients
should be monitored around the time of dose changes for any new symptoms or worsening of disease.


Withdrawal reactions


-- All SSRIs may be associated with withdrawal reactions on stopping or reducing treatment. Paroxetine and venlafaxine seem
to be associated with a greater frequency of withdrawal reactions than other SSRIs. A proportion of SSRI withdrawal reactions
are severe and disabling to the individual.


-- The most commonly experienced withdrawal reactions are dizziness, numbness & tingling, gastrointestinal disturbances
(particularly nausea and vomiting), headache, sweating, anxiety and sleep disturbances.


-- To minimise withdrawal reactions on stopping SSRIs, the dose should be tapered gradually over a period of several weeks,
according to the patient's need.


-- There is no clear evidence that the SSRIs and related antidepressants have a significant dependence liability or show
development of a dependence syndrome according to internationally accepted criteria [either DSM-IV or ICD-10].


Dose response


-- For the majority of SSRIs in the treatment of depressive illness, clinical trial data do not show an additional benefit
from increasing the dose of an SSRI above the recommended daily dose.


-- In the absence of evidence of a benefit from increasing the dose, good practice would be to maintain patients on the
lowest efficacious dose.


-- If a patient is not doing well after starting treatment the possibility of an adverse reaction to the drug should be
considered. Patients should be monitored for signs of restlessness or agitation, particularly at the beginning of treatment.
Increasing the dose in these circumstances may be detrimental.


Use of SSRIs in children and adolescents


-- The balance of risks and benefits for the treatment of depressive illness in under 18s is judged to be unfavourable for
paroxetine (Seroxat), venlafaxine (Efexor), sertraline (Lustral), citalopram (Cipramil), escitalopram (Cipralex) and
mirtazapine (Zispin). It is not possible to assess the balance of risks and benefits for fluvoxamine (Faverin) due to the
absence of paediatric clinical trial data. Only fluoxetine (Prozac) has been shown in clinical trials to be effective in
treating depressive illness in children and adolescents, although it is possible that, in common with the other SSRIs, it is
associated with a small increased risk of self-harm and suicidal thoughts. Overall, the balance of risks and benefits for
fluoxetine in the treatment of depressive illness in under 18's is judged to be favourable.


-- The safety profiles of the different products in clinical trials in children and adolescents differ across studies.
However an increased rate of a number of events including insomnia, agitation, weight loss, headache, tremor, loss of
appetite, self harm and suicidal thoughts were seen in those treated with some of the SSRIs compared with placebo.


Young adults


-- There is no clear evidence of an increased risk of self-harm and suicidal thoughts in young adults of 18 years or over.
However, given that individuals mature at different rates and that young adults are at a higher background risk of suicidal
behaviour than older adults, as a precautionary measure young adults treated with SSRIs should be closely monitored.




Annex 2: NICE guidelines on depression and anxiety


Depression: management of depression in primary and secondary care


Key priorities


Screening in primary care and general hospital settings


-- Screening should be undertaken in primary care and general hospital settings for depression in high-risk groups - for
example, those with a past history of depression, significant physical illnesses causing disability, or other mental health
problems such as dementia.


Watchful waiting


-- For patients with mild depression who do not want an intervention or who, in the opinion of the healthcare professional,
may recover with no intervention, a further assessment should be arranged, normally within 2 weeks ('watchful waiting').

v
Antidepressants in mild depression


-- Antidepressants are not recommended for the initial treatment of mild depression, because the risk-benefit ratio is poor.



Guided self-help


-- For patients with mild depression, healthcare professionals should consider recommending a guided self-help programme
based on cognitive behavioural therapy (CBT).


Short-term psychological treatment


-- In both mild and moderate depression, psychological treatment specifically focused on depression (such as problem-solving
therapy, brief CBT and counselling) of 6 to 8 sessions over 10 to 12 weeks should be considered.
v
Prescription of an SSRI


-- When an antidepressant is to be prescribed in routine care, it should be a selective serotonin reuptake inhibitor (SSRI),
because SSRIs are as effective as tricyclic antidepressants and are less likely to be discontinued because of side effects.



Tolerance and craving, and discontinuation/withdrawal symptoms


-- All patients prescribed antidepressants should be informed that, although the drugs are not associated with tolerance and
craving, discontinuation/withdrawal symptoms may occur on stopping, missing doses or, occasionally, on reducing the dose of
the drug. These symptoms are usually mild and self-limiting but can occasionally be severe, particularly if the drug is
stopped abruptly.


Initial presentation of severe depression


-- When patients present initially with severe depression, a combination of antidepressants and individual CBT should be
considered as the combination is more cost-effective than either treatment on its own.


Maintenance treatment with antidepressants



-- Patients who have had two or more depressive episodes in the recent past, and who have experienced significant functional
impairment during the episodes, should be advised to continue antidepressants for 2 years.


Combined treatment for treatment-resistant depression


-- For patients whose depression is treatment resistant, the combination of antidepressant medication with CBT should be
considered.


CBT for recurrent depression


-- CBT should be considered by patients with recurrent depression who have relapsed despite antidepressant treatment, or who
express a preference for psychological interventions.


Anxiety: management of anxiety (panic disorder, with or without agoraphobia, and generalised anxiety disorder) in adults in
primary, secondary and community care


Key priorities


General management


-- Shared decision-making between the individual and healthcare professionals should take place during the process of
diagnosis and in all phases of care.


-- Patients, and where appropriate, families and carers should be provided with information on the nature, course and
treatment of panic disorder or generalised anxiety disorder, including information on the use and likely side-effect profile
of medication.


-- Patients, families and carers should be informed of self-help groups and support groups and be encouraged to participate
in such programmes where appropriate.


-- All patients prescribed antidepressants should be informed that, although the drugs are not associated with tolerance and
craving, discontinuation/withdrawal symptoms may occur on stopping or missing doses or, occasionally, on reducing the dose of
the drug. These symptoms are usually mild and self-limiting but occasionally can be severe, particularly if the drug is
stopped abruptly.


Step 1: Recognition and diagnosis of panic disorder and generalised anxiety disorder


-- The diagnostic process should elicit necessary relevant information such as personal history, any self-medication, and
culture or other individual characteristics that may be important considerations in subsequent care.


Step 2: Offer treatment in primary care


-- There are positive advantages of services based in primary care practice (for example, lower drop-out rates) and these
services are often preferred by patients.


-- The treatment of choice should be available promptly.


Panic disorder


-- Benzodiazepines are associated with a less good outcome in the long term and should not be prescribed for the treatment of
individuals with panic disorder.


-- Any of the following types of intervention should be offered and the preference of the person should be taken into
account. The interventions that have evidence for the longest duration of effect, in descending order are: (a) psychological
therapy (CBT); (b) pharmacological therapy (an SSRI licensed for panic disorder; or if an SSRI is unsuitable or there is no
improvement, imipramine or clomipramine may be considered1 ); (c) self-help (bibliotherapy based on CBT principles).


Generalised anxiety disorder


-- Benzodiazepines should not usually be used beyond 2-4 weeks.


-- In the longer-term care of individuals with generalised anxiety disorder, any of the following types of intervention
should be offered and the preference of the person with generalised anxiety disorder should be taken into account. The
interventions that have evidence for the longest duration of effect, in descending order, are: (a) psychological therapy
(CBT); (b) pharmacological therapy (an SSRI); (c) self-help (bibliotherapy based on CBT principles).


Step 3: Review and offer alternative treatment


-- If one type of intervention does not work, the patient should be reassessed and consideration given to trying one of the
other types of intervention.


Step 4: Review and offer referral from primary care


-- In most instances, if there have been two interventions provided (any combination of psychological therapy, medication or
bibliotherapy) and the person still has significant symptoms, then referral to specialist mental health services should be
offered.


Step 5: Care in specialist mental health services


-- Specialist mental health services should conduct a thorough, holistic, reassessment of the individual, their environment
and their social circumstances.


Monitoring


-- Short, self-complete questionnaires (such as the panic subscale of the agoraphobic mobility inventory for individuals with
panic disorder) should be used to monitor outcomes wherever possible.


Obtaining copies of the guidelines


Electronic copies of the quick reference guide to the anxiety guideline can be found on the NICE website at nice.uk/CG022quickrefguide and electronic
copies of the information for the public leaflet that accompanies the guideline can be found at nice.uk/CG022publicinfo.


Electronic copies of the quick reference guide to the depression guideline can be found on the NICE website at nice.uk/CG023quickrefguide and electronic
copies of the information for the public leaflet that accompanies the guideline can be found at nice.uk/CG023publicinfo.


Hard copies of both guidelines will be distributed to the NHS on 15th December and will be available to order from the NHS
Response Line on 0870 1555 455 from that date, by quoting the following reference numbers:


1Imipramine and clomipramine are not licensed for panic disorder but have been shown to be effective in its management.




-- N0766 - depression quick reference guide


-- N0767 - depression information for the public (English)


-- N0768 - depression information for the public (English and Welsh bilingual)


-- N0763 - anxiety quick reference guide


-- N0764 - anxiety information for the public (English)


-- N0765 - anxiety information for the public (English and Welsh bilingual)

mhra.uk/


View drug information on Clomipramine hydrochloride; Prozac Weekly.