Anxiety Disorders: Johns Hopkins University

Safer DJ. · Johns Hopkins University School of Medicine, Departments of Psychiatry and Pediatrics, Baltimore, Maryland, USA. · Pediatrics. · Pubmed #16951019 links to  free full text

This publication has no abstract.

Grados MA. · Johns Hopkins University School of Medicine, 600 North Wolfe Street, CMSC 346, Baltimore, MD 21287, USA. · Curr Psychiatry Rep. · Pubmed #19302771 No free full text.

Abstract: Genetic discovery in obsessive-compulsive disorder and Tourette's syndrome has made significant progress in the past decade. The two disorders are phenomenologically, epidemiologically, and probably pathophysiologically related; however, as with most neuropsychiatric disorders, gene discovery has been challenging. Genetic epidemiology studies support the existence of susceptibility genes in both disorders, and more extensive genome-wide studies are under way. Gene pathways involving neurotransmitter (serotonin, dopamine, glutamate) and neurodevelopment (synaptic, homeobox) domains have been examined, but more complex genetic mechanisms remain largely unexplored. This review addresses the current state of genetic research in obsessive-compulsive disorder and Tourette's syndrome, emphasizing commonalities between the disorders. Questions on common genetic substrates, the use of endophenotypes, and the utility of genetic data to inform pharmacologic treatment are also addressed.

Ginsburg GS, Kingery JN, Drake KL, Grados MA. · Division of Child and Adolescent Psychiatry, Johns Hopkins University School of Medicine, 600 North Wolfe Street/CMSC 340, Baltimore, MD 21287-3325, USA. · J Am Acad Child Adolesc Psychiatry. · Pubmed #18596553 No free full text.

Abstract: OBJECTIVE: To examine predictors of treatment response in pediatric obsessive-compulsive disorder (OCD). METHOD: A literature review of psychotherapy (i.e., cognitive-behavioral therapy) and medication studies for pediatric OCD published from 1985 to 2007 was conducted using several databases. RESULTS: The literature search produced a total of 21 studies (6 cognitive-behavioral therapy, 13 medication, and 2 combination studies) that met specific methodological criteria. Across studies, the following nine predictors were examined: child sex, child age, duration of illness/age at onset, baseline severity of obsessive-compulsive symptoms, type of obsessive-compulsive symptoms, comorbid disorders/symptoms, psychophysiological factors, neuropsychological factors, and family factors. Among all of the studies, there was little evidence that sex, age, or duration of illness (age at onset) was associated with treatment response. Baseline severity of obsessive-compulsive symptoms and family dysfunction were associated with poorer response to cognitive-behavioral therapy, whereas comorbid tics and externalizing disorders were associated with poorer response in medication-only studies. CONCLUSIONS: Overall, there are limited data on predictors of treatment response for pediatric OCD. The majority of studies are plagued with methodological limitations and post hoc approaches. Additional research is needed to better delineate the predictors of treatment response in pediatric OCD with the goal of developing individualized treatment approaches.

Gruber N. · Weinberg Intensive Care Unit, The Johns Hopkins Hospital, Baltimore, USA. · RN. · Pubmed #18564775 No free full text.

This publication has no abstract.

Alhusen JL. · School of Nursing, Johns Hopkins University, Baltimore, MD 21205, USA. · J Obstet Gynecol Neonatal Nurs. · Pubmed #18507602 No free full text.

Abstract: OBJECTIVE: To critically review and synthesize original research published since 2000 designed to measure factors that influence maternal-fetal attachment. DATA SOURCES: EBSCOhost Research Databases that included PubMed, CINAHL Plus, PsycINFO, and SCOPUS were searched for journal articles published in the past 7 years (2000-2007) that examined variables thought to increase, decrease, or cause no change in level of maternal-fetal attachment. Keyword searches included maternal-fetal attachment, parental attachment, and prenatal attachment. STUDY SELECTION: Twenty-two studies were selected that met the inclusion criteria of original research, clear delineation of the measurement of maternal-fetal attachment, measurement of maternal-fetal attachment during pregnancy, and inclusion of women or couples, or both. DATA EXTRACTION: Studies measuring maternal-fetal attachment included a broad range of variables as potential risk or protective factors, or both. Factors associated with higher levels of maternal-fetal attachment included family support, greater psychological well-being, and having an ultrasound performed. Factors such as depression, substance abuse, and higher anxiety levels were associated with lower levels of maternal-fetal attachment. DATA SYNTHESIS: The large majority of studies reviewed were limited by small, homogenous samples deemed insufficient to detect significant differences, inconsistent measurement of maternal-fetal attachment during gestational periods, and cross-sectional designs. CONCLUSIONS: Further research is essential to identify factors influencing maternal-fetal attachment. Specifically, research needs to be conducted on larger sample sizes of greater racial and ethnic diversity.

Jennett HK, Hagopian LP. · Department of Behavioral Psychology, Kennedy Krieger Institute, Baltimore, MD 21205, USA. · Behav Ther. · Pubmed #18502248 No free full text.

Abstract: This paper reviews the literature regarding the treatment of phobic avoidance in individuals with intellectual disabilities. Criteria for classifying interventions as empirically supported, developed by the American Psychological Association (APA) Division 12 Task Force on Promotion and Dissemination of Psychological Procedures, were used. For studies employing single case experimental designs, criteria developed by APA Division 16 (Kratochwill & Stoiber, 2002; Shernoff, Kratochwill, & Stoiber, 2002) were used to supplement Division 12 criteria. Results indicate that behavioral treatment can be designated as a well-established treatment for phobic avoidance in individuals with intellectual disabilities.

Davydow DS, Desai SV, Needham DM, Bienvenu OJ. · Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. · Psychosom Med. · Pubmed #18434495 No free full text.

Abstract: OBJECTIVE: Acute lung injury (ALI), including its more severe subcategory, acute respiratory distress syndrome (ARDS), is a critical illness associated with considerable morbidity and mortality. Our objective was to summarize data on the prevalence of depressive, posttraumatic stress disorder (PTSD), and other anxiety syndromes amongst survivors of ALI/ARDS, potential risk factors for these syndromes, and their relationships to quality of life. METHODS: We conducted a systematic literature review using Medline, EMBASE, Cochrane Library, CINAHL, and PsycINFO. Eligible studies reported data on psychiatric morbidity at least once after intensive care treatment of ALI/ARDS. RESULTS: Ten observational studies met inclusion criteria (total n = 331). Using questionnaires, the point prevalence of "clinically significant" symptoms of depression ranged from 17% to 43% (4 studies); PTSD, 21% to 35% (4 studies); and nonspecific anxiety, 23% to 48% (3 studies). Studies varied in terms of instruments used, thresholds for clinical significance, baseline psychiatric history exclusions, and timing of assessments (range = 1 month to 8 years). Psychiatrist-diagnosed PTSD prevalence at hospital discharge, 5 years, and 8 years were 44%, 25%, and 24%, respectively. Three studies prospectively assessed risk factors for post-ALI/ARDS PTSD and depressive symptoms; significant predictors included longer durations of mechanical ventilation, intensive care unit stay, and sedation. All four studies that examined relationships between psychiatric symptoms and quality of life found significant negative associations. CONCLUSIONS: The prevalence of psychiatric morbidity in patients surviving ARDS seems high. Future research should incorporate more in-depth diagnostic and risk factor assessments for prevention and monitoring purposes.

Grados M, Riddle MA. · Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA. · Int Rev Psychiatry. · Pubmed #18386211 No free full text.

Abstract: Obsessive-compulsive disorder (OCD) in children is strikingly similar in clinical presentation and treatment responsiveness to OCD in adults. While treatment is commonly effective for OCD not all subtypes of OCD are similarly responsive to treatment. Numerous studies describe the differential responsiveness of OCD subtypes to pharmacological treatment in adults, yet few such studies exist in pediatric OCD. This manuscript reviews the extant literature that addresses differential response of OCD subtypes to medication intervention. Specific OCD subtypes can be derived utilizing the following strategies: symptom factor analysis, comorbidity latent class analysis, concurrent internalizing disorders, concurrent externalizing disorders, tic-related subtype and early-onset subtype are reviewed in relation to data on differential pharmacotherapy response. Only externalizing disorders moderate treatment response in pediatric OCD. Specifically, attention-deficit hyperactivity disorder, oppositional defiant disorder and conduct disorder are associated with poorer response to medication treatment. Hoarding appears to be associated with a poor response to medication in adults, but data are sparse in children. The presence of tic disorders may also predict poorer response to pharmacotherapy in pediatric OCD. Strategies for treatment of the tic-related subtype of OCD, while strongly supporting the use of antipsychotic-augmentation for enhanced response in adults, are lacking controlled data in pediatric OCD.

Keeton CP, Ginsburg GS. · Division of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287-3325, USA. · Int Rev Psychiatry. · Pubmed #18386206 No free full text.

Abstract: Despite the absence of data on the efficacy of combination therapy (i.e., psychosocial and medication) for the treatment of anxiety disorders in youths, clinicians in clinical practice often utilize this treatment approach. This paper discusses issues related to sequencing, combining, and integrating cognitive behavioural and pharmacological interventions for anxiety disorders in children and adolescents. We briefly summarize the empirical evidence for mono and combination therapy and raise a variety of issues that should be considered when making treatment decisions. Finally, we present an integrated treatment model to facilitate the delivery of a comprehensive treatment approach across care providers. These suggestions are geared toward optimizing clinical outcomes for anxious youths.

Wise TN. · Johns Hopkins University School of Medicine, Baltimore, MD, USA. · Curr Opin Psychiatry. · Pubmed #18332670 No free full text.

Abstract: PURPOSE OF REVIEW: Current issues in consultation-liaison psychiatry, which is now labeled psychosomatic medicine as a formal subspecialty by the American Board of Psychiatry and Neurology, are discussed. RECENT FINDINGS: There is continued interest in how to best manage depression and anxiety in a primary-care setting. Collaborative care that utilizes a psychiatrist within the treatment center, as well as case management by a nurse, have been reviewed and meta-analyses suggest it is an efficient and effective approach. The diagnostic issues within psychosomatic medicine are also an area of concern as the Diagnostic and Statistical Manual of Mental Disorders, 5 edition, is in the planning stages. How to improve both the reliability and validity of somatoform disorders will be a major challenge. Organ transplantation is a clinical challenge for patients, donors and healthcare providers. Issues in assessment and management continue to evolve. Ethical questions also arise due to the shortage of available organs. SUMMARY: Psychosomatic medicine continues to manage patients in medical settings that cut across a continuum from primary-care to complex medical and surgical centers. The clinical problems containing a medical-psychiatric interface offer a clinical challenge but also an area for new knowledge and better interventions.

McCabe OL, Kaminsky MJ, McHugh PR. · Department of Mental Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA. · Am J Disaster Med. · Pubmed #18297950 No free full text.

Abstract: Despite increased professional attention to the mental health aspects of disaster medicine in recent years, advances in clinical assessment of survivors of mass casualty incidents have been few. Contemporary assessment methods often yield little more than check lists of symptoms that, while they may lead to reliable DSM-IV diagnoses, provide no sense of the individual patient's plight and so are inadequate for case formulation, treatment planning, and prognosis estimation. The authors describe a comprehensive model for assessing patients developed at the Johns Hopkins Department of Psychiatry and Behavioral Sciences. Relating it to the field of disaster mental health for the first time here, the approach uses four distinct but overlapping appraisal perspectives, each of which drives a set of exploratory propositions and leads to an understanding of the essential natures of clinical disorders and their underlying etiologies. The perspectives address the following: (a) what the individual "has" (biologically based disease and physical illness); (b) who the individual "is" (graded dimensions of temperament, disposition, traits, intelligence, etc); (c) what the individual "does" (purposeful, goal-directed, conditioned behavior, etc); and (d) what the individual "has encountered" (his/ her life story and the meaning that has been given to those experiences). Following a description of each perspective from the standpoint of its underlying logic, inquiry domain, and indicated intervention, the authors highlight the potential hueristic value of the model by illustrating numerous testable hypotheses that can be generated through the juxtaposition of the four assessment perspectives with three longitudinal considerations for the management of trauma patients, ie, the stress-related constructs of (pre-incident) resistance, (peri-incident) resilience, and (post-incident) recovery.

Bienvenu OJ, Ginsburg GS. · Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, USA. · Int Rev Psychiatry. · Pubmed #18092242 No free full text.

Abstract: Anxiety disorders are very common and burdensome conditions with early onsets. Thus, there has recently been increasing interest in preventing these illnesses. In this article we review recent prevention studies targeting populations at varying levels of risk and conclude that prevention using cognitive-behavioural interventions is promising, though establishing longer-term effects and the cost-effectiveness of such interventions are important next steps for the field. We discuss conceptual and practical issues with regard to prevention of anxiety disorders and note that theory-based models of prevention which are based on identified risk and protective factors, address the optimal timing of intervention delivery, and articulate specific mechanisms of action are greatly needed.

Grados M, Wilcox HC. · The Johns Hopkins University, CMSC 346, Baltimore, MD 21287-3325, USA. · Expert Rev Neurother. · Pubmed #17678492 No free full text.

Abstract: The genetic study of obsessive-compulsive disorder (OCD) has made significant gains in the past decade. However, etiological gene findings are still elusive. Epidemiological studies, including family and twin studies, strongly support a genetic component for OCD. In addition, complex segregation analyses suggest the presence of at least one major gene. The neurobiology of OCD also lends support to the notion that programmed CNS-based biological processes underlie OCD symptom expression, with mapping of brain circuits to fronto-subcortical circuits in a consistent manner. Genetic linkage studies of OCD, using families with multiple affected relatives, have generated several suggestive linkage peaks, regions that may harbor a gene or genes for OCD. However, the presence of multiple linkage peaks has added to the complexity of OCD genetics, suggesting that the exploration of gene-gene interactions and gene-environment interactions, in addition to the exploration of alternate phenotypes based on symptom expression, age at onset or comorbid conditions, may be key in locating etiologic genes. Finally, candidate gene studies, while promising, are not yet associated with linkage regions, except in the case of the glutamate transporter gene SLC1A1 in 9p24. While OCD appears to have a genetic component, additional innovative research is needed to unravel the genetic influences in the disorder.

Fauerbach JA, Pruzinsky T, Saxe GN. · Johns Hopkins Burn Center, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, Baltimore, MD 21224, USA. · J Burn Care Res. · Pubmed #17514031 No free full text.

This publication has no abstract.

Hall RC, Hall RC. · Department of Psychiatry and Behavioral Sciences, Johns Hopkins Hospital, 600 North Wolfe Street/Meyer 113, Baltimore, MD 21287-7113, USA. · J Forensic Sci. · Pubmed #17456103 No free full text.

Abstract: Posttraumatic stress disorder (PTSD) is a condition that can be easily malingered for secondary gain. For this reason, it is important for physicians to understand the phenomenology of true PTSD and indicators that suggest an individual is malingering. This paper reviews the prevalence of PTSD for both the general population and for specific events, such as rape and terrorism, to familiarize evaluators with the frequency of its occurrence. The diagnostic criteria for PTSD, as well as potential ambiguities in the criteria, such as what constitutes an exposure to a traumatic event, are reviewed. Identified risk factors are reviewed as a potential way to help differentiate true cases of PTSD from malingered cases. The question of symptom overreporting as a feature of the disease versus a sign of malingering is discussed. We then examine how the clinician can use the clinical interview (e.g., SIRS, CAPS), psychometric testing, and the patient's physiological responses to detect malingering. Particular attention is paid to research on the MMPI and the subscales of infrequency (F), infrequency-psychopathology (Fp), and infrequency-posttraumatic stress disorder (Fptsd). Research and questions regarding the accuracy of self-report questionnaires, specifically the Mississippi Scale (MSS) and the Personality Assessment Inventory (PAI), are examined. Validity, usability, and cutoff values for other psychometric tests, checklists, and physiological tests are discussed. The review includes a case, which shows how an individual used symptom checklist information to malinger PTSD and the inconsistencies in his story that the evaluator detected. We conclude with a discussion regarding future diagnostic criteria and suggestions for research, including a systematic multifaceted approach to identify malingering.

Wittstein IS. · Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA. · Cleve Clin J Med. · Pubmed #17455537 links to  free full text

This publication has no abstract.

Reinblatt SP, Riddle MA. · Department of Psychiatry and Behavioral Sciences, Division of Child and Adolescent Psychiatry, The Johns Hopkins University School of Medicine, 600 N. Wolfe St., CMSC 312, Baltimore, MD, USA. · Psychopharmacology (Berl). · Pubmed #17205317 No free full text.

Abstract: RATIONALE: Pediatric anxiety is a prevalent psychiatric disorder that may have important implications for school, social, and academic function. Psychopharmacological approaches to the treatment of pediatric anxiety have expanded over the past 20 years and increasing empirical evidence helps guide current clinical practice. OBJECTIVE: To review studies which examine the pharmacological treatment of pediatric anxiety disorders, including obsessive-compulsive disorder and to summarize treatment implications. METHODS: All relevant studies were searched using MEDLINE and PsycINFO search engines, supplemented by a manual bibliographical search; studies published between 1985 and 2006 that met inclusion criteria were examined. RESULTS: This article provides a systematic review of the psychopharmacological treatment of pediatric anxiety disorders based on available empirical evidence, with a focus on randomized controlled trials. General treatment principles and pharmacological management of specific pediatric anxiety disorders are also reviewed. CONCLUSION: There is good evidence to support the efficacy of several pharmacological agents including the selective serotonin reuptake inhibitors to treat pediatric anxiety and obsessive-compulsive disorder, although there are still many unanswered questions.

MacKinnon DF, Zamoiski R. · Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Meyer 3-181, 600 N. Wolfe Street, Baltimore, MD 21287, USA. · Bipolar Disord. · Pubmed #17156152 No free full text.

Abstract: CONTEXT: Bipolar/panic comorbidity has been observed in clinical, community and familial samples. As both are episodic disorders of affect regulation, the common pathophysiological mechanism is likely to involve deficits in amygdala-mediated, plasticity-dependent emotional conditioning. EVIDENCE: Neuronal genesis and synaptic remodeling occur in the amygdala; bipolar and panic disorders have both been associated with abnormality in the amygdala and related structures, as well as in molecules that modulate plasticity, such as serotonin, norepinephrine, brain-derived neurotrophic factor (BDNF) and corticotrophin releasing factor (CRF). These biological elements are involved in behavioral conditioning to threat and reward. MODEL: Panic attacks resemble the normal acute fear response, but are abnormally dissociated from any relevant threat. Abnormal reward-seeking behavior is central to both manic and depressive syndromes. Appetites can be elevated or depressed; satisfaction of a drive may fail to condition future behavior. These dissociations may be the result of deficits in plasticity-dependent processes of conditioning within different amygdala subregions. CONCLUSIONS: This speculative model may be a useful framework with which to connect molecular, cellular, anatomic and behavioral processes in panic and bipolar disorders. The primary clinical implication is that behavioral treatment may be critical to restore function in some bipolar patients who respond only partially to medications.

Hall RC, Hall RC. · Department of Psychiatry and Behavioral Sciences, Johns Hopkins Hospital, 600 N. Wolfe Street/Meyer 113, Baltimore, MD 21287-7113, USA. · Gen Hosp Psychiatry. · Pubmed #17088169 No free full text.

Abstract: OBJECTIVE: This paper aims to study the detection of individuals malingering posttraumatic stress disorder (PTSD) in criminal and civil situations. METHOD: A brief history of PTSD and its rise to prominence in legal circles are discussed. The characteristics of individuals who malinger and particularly those who fake PTSD are discussed. Diagnostic dilemmas inherent to the condition, such as the definition of a traumatic exposure, what constitutes a PTSD flashback and the potential for normal symptom exaggeration, are explored. RESULTS: The typical presentation of malingered symptoms is presented to help clinicians detect commonly seen malingering patterns. Suggestions for interview techniques, Minnesota Multiphasic Personality Inventory test values and sources of collateral information to help detect malingering are reviewed. CONCLUSION: The paper concludes with a review of the typical presentations of malingered PTSD symptoms and a reminder that physicians need to distinguish legitimate symptoms from faked or embellished presentations.

McHugh PR, Treisman G. · Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA. · J Anxiety Disord. · Pubmed #17085011 No free full text.

Abstract: Since the publication of Diagnostic and Statistical Manual of Mental Disorders (DSM)-III, posttraumatic stress disorder (PTSD) has become a remarkably dominant theme in mental health discourse and diagnostic practice. This development has been encouraged by the diagnosis being officially presumed to exist in acute, chronic, delayed, complex, subdromal, and even "masked" forms. Here, we present an historical and clinical review that indicates how, since 1980, the term PTSD (along with its dubious embellishments) replaced established views on mental responses to trauma to the detriment of patient care and psychiatric investigation. From this historical perspective, we review and evaluate the natural course of emotional and behavioral reactions to traumatic experiences, and as well their assessment, formulation, and therapeutic management in both civilian and military situations. From this we conclude that the concept of PTSD has moved the mental health field away from, rather than towards a better understanding of the natural psychological responses to trauma. A return to prior standards of diagnostic practice and therapeutic planning would greatly benefit patient care, rehabilitative services to veterans, and epidemiologic research.

Gaze C, Kepley HO, Walkup JT. · Division of Child and Adolescent Psychiatry, Johns Hopkins University School of Medicine, Baltimore, MD 21287-3325, USA. · J Child Neurol. · Pubmed #16970866 No free full text.

Abstract: More than half of all children and adolescents with Tourette syndrome show evidence of psychiatric comorbidity, exhibiting symptoms of attention-deficit hyperactivity disorder (ADHD), obsessive-compulsive disorder, and other anxiety and mood disorders. Although the prevalence of co-occurring conditions varies depending on the clinical setting, it is crucial for clinicians to be familiar with these disorders because they are often more impairing than tics and can influence the initial treatment choice. Left untreated, these conditions can negatively affect important developmental outcomes, such as academic and social functioning. We review the most common co-occurring disorders, the relationship of these co-occurring disorders to Tourette syndrome, and treatment recommendations for co-occurring conditions when tic symptoms are present.

Brandes M, Bienvenu OJ. · Johns Hopkins Hospital, 600 North Wolfe Street, Meyer 115, Baltimore, MD 21287, USA. · Curr Psychiatry Rep. · Pubmed #16879789 No free full text.

Abstract: Personality traits and most anxiety disorders are strongly related. In this article, we review existing evidence for ways in which personality traits may relate to anxiety disorders: 1) as predisposing factors, 2) as consequences, 3) as results of common etiologies, and 4) as pathoplastic factors. Based on current information, we conclude the following: 1) Personality traits such as high neuroticism, low extraversion, and personality disorder traits (particularly those from Cluster C) are at least markers of risk for certain anxiety disorders; 2) Remission from panic disorder is generally associated with partial "normalization" of personality traits; 3) Anxiety disorders in early life may influence personality development; 4) Anxiety disorders and personality traits are usefully thought of as spectra of common genetic etiologies; and 5) Extremes of personality traits indicate greater dysfunction in patients with anxiety disorders.

Gill JM, Page GG. · School of Nursing, Johns Hopkins University, Baltimore, Maryland 21205, USA. · Issues Ment Health Nurs. · Pubmed #16849259 No free full text.

Abstract: All individuals are at some risk of experiencing a traumatic event and developing posttraumatic stress disorder (PTSD); however some individuals are at higher risk due to individual and environmental factors. This critical literature review focuses on women, as they are twice as likely as men to develop PTSD in their lifetimes. Should a woman develop PTSD, she is then at risk of developing psychiatric and physical health comorbidities that can further impact her quality of life. The strengths and limitations of current studies regarding this topic are discussed as are directions for future research and issues for nurses treating traumatized individuals.

Capone G, Goyal P, Ares W, Lannigan E. · Down Syndrome Clinic (DSC) at Kennedy Krieger Institute, 707 N. Broadway, Baltimore MD 21205, USA. · Am J Med Genet C Semin Med Genet. · Pubmed #16838318 No free full text.

Abstract: The term dual-diagnosis refers to a person with mental retardation and a psychiatric disorder. Most children with Down syndrome (DS) do not have a psychiatric or neurobehavioral disorder. Current prevalence estimates of neurobehavioral and psychiatric co-morbidity in children with DS range from 18% to 38%. We have found it useful to distinguish conditions with a pre-pubertal onset from those presenting in the post-pubertal period, as these are biologically distinct periods each with a unique vulnerability to specific psychiatric disorders. Due to the increased recognition that psychiatric symptoms may co-occur with mental retardation, and are not inextricably linked to cognitive impairment, these conditions are considered treatable, in part, under a medical model. Improvement in physiologic regulation, emotional stability, and neurocognitive processing is one of the most elusive but fundamental goals of pharmacologic intervention in these disorders.

Chander G, Himelhoch S, Moore RD. · Department of Medicine, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Baltimore, MD 21287, USA. · Drugs. · Pubmed #16706551 No free full text.

Abstract: There is a high prevalence of substance abuse and psychiatric disorders among HIV-infected individuals. Importantly, drug and alcohol-use disorders are frequently co-morbid with depression, anxiety and severe mental illness. Not only do these disorders increase the risk of contracting HIV, they have also been associated with decreased highly active antiretroviral therapy (HAART) utilisation, adherence and virological suppression. The literature evaluating the relationship between substance abuse and HIV outcomes has primarily focused on injection drug users, although there has been increasing interest in alcohol, cocaine and marijuana. Similarly, the mental health literature has focused largely on depression, with a lesser focus on severe mental illness or anxiety. To date, there is little literature evaluating the association between co-occurring HIV, substance abuse and mental illness on HAART uptake, adherence and virological suppression. Adherence interventions in these populations have demonstrated mixed efficacy. Both directly observed therapy and pharmacist-assisted interventions appear promising, as do integrated behavioural interventions. However, the current intervention literature has several limitations: few of these studies are randomised, controlled trials; the sample sizes have generally been small; and co-occurring substance abuse and mental illness has not specifically been targeted in these studies. Future studies examining individual substances of abuse, psychiatric disorders and co-occurring substance abuse and psychiatric disorders on HIV outcomes will inform targeted adherence interventions.