In This Issue

The suicide rate of HIV-positive men in Switzerland before the 1996 introduction of antiretroviral therapy was 13.7 times as high as in the general population, but in the following 8 years it was 3.5 times as high. The rate in women fell from 11.6 to 5.7 times the overall rate. Keiser et al. (CME p. 143) found that most HIV patients who died by suicide had mental disorders, and 30% of those affected had received no psychiatric care.

Patients with severe mental illness who received medical care management for 1 year obtained more preventive services and services for cardiac and metabolic conditions than patients who received usual care. The intervention described by Druss et al. (p. 151) was provided by two registered nurses to 407 mentally ill patients. At least one primary care visit during follow-up was documented for 71% of the patients receiving medical care management and 52% of those receiving usual care. The care management group also had an 8% increase in mental-health-related quality of life, compared with a 1% decrease for usual care. Dr. Michael Flaum discusses health care for the mentally ill on p. 120.

A 32-year study tracking 1,037 children demonstrates that in those who later developed schizophrenia, some cognitive impairments were apparent at age 7 and remained stable, whereas other cognitive problems emerged between childhood and adolescence. Reichenberg et al. (CME, p. 160) report that scores at age 7 for knowledge acquisition, reasoning, and conceptualization were lower in the children who later developed schizophrenia. Differences in attention, processing speed, visual-spatial problem solving, and working memory only became apparent between ages 7 and 13. Dr. Wendy Kates points out important developmental aspects of this study in an editorial on p. 122.

Depot olanzapine is a newly released formulation. This issue presents a clinical study (Kane, p. 181) comparing various depot intramuscular doses with daily oral dosing for patients already well maintained with 10–20-mg daily oral doses. They continued to take their oral medication or switched to one of four doses of the new depot formulation: 300 mg/2 weeks, 405 mg/4 weeks, 150 mg/2 weeks, or 45 mg/4 weeks. The study thus provides a dose-response curve for efficacy and side effects of the depot formulation. As seen in the figure, the patients taking the lowest depot dose had significantly more relapses over the 24-week study (>30%) than did the patients taking the highest dose (5%). The patients who continued to take oral doses did as well as patients taking the higher depot doses, with 7% relapsing with the oral doses. Weight gain greater than 7% was also similar in the oral doses and the highest depot dose, with 20% of patients affected. In his editorial (p. 125), Dr. John Davis suggests that depot medications continue to be a safe and effective alternative for the patient who cannot comply with oral medication.

ECT treatment of a 19-year-old woman with manic excitement followed by a lengthy period of catatonia is described in this month’s Clinical Case Conference (Zisselman, p. 127). Immobility, refusal of food and fluids, and a rising temperature and CPK led to a diagnosis of malignant catatonia that was unresponsive to amantadine, bromocriptine, and lorazepam. Muscle damage due to the catatonia complicated premedication with succinylcholine because of hyperkalemia that resulted in cardiac arrhythmia. The patient was also unable to provide consent, which necessitated a family guardian. The patient responded to bilateral ECT after premedication with rocuronium, a nondepolarizing muscle relaxant.

ECT for catatonia in an 18-year-old girl with autism was featured in a 2008 Clinical Case Conference. Similar clinical features for this patient were injury from her catatonic posturing and the requirement for bilateral ECT (Wachtel, Am J Psychiatry 2008; 165:329–333).