OBJECTIVE: This study attempted to systematically assess the experiences of Medicare and Medicaid "dual-eligible" psychiatric patients, including evaluating patients’ access to medications and the administrative functioning of the program, during the first 4 months of the Medicare Part D prescription drug benefit. METHOD: Psychiatrists (N=5,833) were randomly selected from the American Medical Association’s Physicians Masterfile. After exclusion of those not practicing and with undeliverable addresses, 64% responded; 35% met study eligibility criteria of treating at least one dual-eligible patient during their last typical workweek and reported clinically detailed information on one systematically selected patient. RESULTS: A total of 53.4% had at least one medication access problem to report between Jan. 1 and April 30, 2006. Although 9.7% experienced improved medication access, 22.3% discontinued or temporarily stopped taking medication because of prescription drug coverage or management issues, and 18.3% were previously stable but were required to switch medications. Among those with medication access problems, 27.3% experienced a significant adverse clinical event; 19.8% had an emergency room visit. Most drug plan features studied, including preferred drug/formulary lists, prior authorization, medication dosing/number limits, "fail-first" protocols, and requirements to switch to generics, were associated with significantly higher rates of medication access problems. CONCLUSIONS: The findings indicate consequential medication access problems for psychiatric patients during the implementation of Medicare Part D. Although Centers for Medicare and Medicaid Services policies were enacted to ensure access to protected classes of psychopharmacologic medications, the high rates of medication access problems observed indicate further refinement of these policies is needed.

OBJECTIVE: Both methadone and buprenorphine are effective therapy for heroin dependence. Efficacy is best documented for methadone maintenance therapy, but safety concerns limit its use. Buprenorphine offers lower overdose risk and improved access, but efficacy may be lower. The authors compared adaptive, buprenorphine-based stepped care to optimal methadone maintenance treatment. METHOD: This randomized controlled trial was undertaken 2004–2006. It consisted of a 24-day uniform double-blind induction phase followed by single-blind flexible dosing based on structured clinical criteria, for a total of 6 months. Ninety-six self-referred subjects with heroin dependence were randomly assigned to methadone or to stepped treatment initiated with buprenorphine/naloxone and escalated to methadone if needed. All subjects received intensive behavioral treatment. Primary outcome was retention in treatment. Secondary outcomes were completer analyses of problem severity (Addiction Severity Index) and proportion of urine samples free of illicit drugs. RESULTS: Overall, 6-month retention was 78%. Stepped treatment and methadone maintenance therapy outcomes were virtually identical. Among completers of stepped therapy, 46% remained on buprenorphine/naloxone. Proportion of urine samples free of illicit opiates increased over time and ultimately reached approximately 80% in both arms. Problem severity decreased significantly and uniformly in both arms. CONCLUSIONS: A stepped treatment of heroin dependence as described here appears equally efficacious compared to optimally delivered methadone maintenance therapy. Together with prior data on the advantageous safety of buprenorphine, this suggests that broad implementation of strategies using buprenorphine as first-line treatment should be considered.

OBJECTIVE: Several components of event-related potentials—P50 suppression, P300 amplitude and latency, and mismatch negativity—have been proposed as potential endophenotypes for schizophrenia on the basis of family studies. The present study used a twin design to estimate the extent of genetic overlap between these indices and the liability to schizophrenia. METHOD: The authors measured mismatch negativity, P300, and P50 suppression in 16 monozygotic twin pairs concordant for schizophrenia, nine monozygotic twin pairs discordant for schizophrenia, and 78 healthy comparison twin pairs. The study design was based on a power calculation. Structural equation modeling was used to quantify the genetic and environmental contributions to the phenotypic covariance between schizophrenia and each of the event-related potential indices. RESULTS: Significant phenotypic correlation with schizophrenia was found for each of the event-related potential components. Genetic factors were the main source of the phenotypic correlations. P50 suppression had the greatest genetic correlation with schizophrenia, followed by P300 amplitude, P300 latency, and mismatch negativity. CONCLUSIONS: All four event-related potential indices are potentially valid endophenotypes for schizophrenia, but P50 suppression and P300 amplitude show the closest genetic relationship to schizophrenia.

OBJECTIVE: Genetic factors contribute to the development of schizophrenia where cognitive dysfunction is a hallmark. The purpose of this article was to examine computerized neurocognitive measures as candidate endophenotypic markers of liability for schizophrenia in a genetically informative cohort. METHOD: European Americans from 35 multiplex multigenerational families (N=349) and healthy participants (N=154) underwent clinical assessments and neurocognitive measurements and provided blood samples. The neurocognitive measures included performance (accuracy and speed) from a computerized battery that assessed abstraction/mental flexibility; attention; verbal, face, and spatial memory; spatial processing; sensorimotor processing; and emotion intensity discrimination. RESULTS: Probands, relatives, and comparison subjects differed from each other in performance. Probands demonstrated greatest impairment relative to comparison subjects, followed by family members. Liability for schizophrenia affected the speed-accuracy tradeoff differently for specific neurocognitive domains. Significant heritability estimates were obtained for accuracy of verbal, facial, and spatial memory and spatial and emotion processing. For speed, estimates of heritability were significant for abstraction/mental flexibility, attention, face memory, and spatial and sensorimotor processing. CONCLUSIONS: In a multigenerational multiplex design, the authors demonstrated that neurocognitive measures are associated with schizophrenia, differentiate unaffected relatives from comparison subjects, and may have significant presumed heritability. Therefore, they are endophenotypes suitable for genetic studies. Accuracy and speed can be differentially sensitive to presumed genetic liability.

OBJECTIVE: The assessment of self-injurious thoughts has been limited by a reliance on what individuals are willing or able to report explicitly. The authors examined a new method that measures self-injurious thoughts by using individuals’ reaction times to self-injury-related stimuli on a computerized test. METHOD: Eighty-nine adolescents who were not self-injurious (N=36) or had recently engaged in nonsuicidal self-injury (N=53) completed two versions of the Self-Injury Implicit Association Test, which measure the automatic association of self-injury with oneself and with favorableness. Results The tests revealed significant behavioral differences between the self-injurers and noninjurers. Moreover, test scores significantly improved the statistical prediction of nonsuicidal self-injury beyond that achieved with demographic and psychiatric factors. CONCLUSIONS: These initial results support the validity of the Self-Injury Implicit Association Test as a performance-based measure of self-injurious thoughts. Future research should further examine the usefulness of incorporating implicit measures in risk assessment and decision-making procedures for self-injury and other sensitive clinical behaviors.

OBJECTIVE: The aim of this study was to explore the microstructural integrity of whole-brain white matter by diffusion tensor imaging in first-episode, treatment-naive young adults with major depressive disorder. METHOD: Diffusion tensor imaging scans were obtained from 14 first-episode, treatment-naive young adult patients with major depressive disorder and 14 healthy comparison subjects. A voxel-based method was used to analyze the scans. RESULTS: The patient group exhibited significantly lower fractional anisotropy values than healthy comparison subjects in the white matter of the right middle frontal gyrus, the left lateral occipitotemporal gyrus, and the subgyral and angular gyri of the right parietal lobe. There were no regions of significantly higher fractional anisotropy values in patients compared with healthy comparison subjects. CONCLUSIONS: These findings suggest that abnormalities of brain white matter may be present early in the course of major depressive disorder. They also support the idea that white matter lesions may disrupt the neural circuits involved in mood regulation and thus contribute to the neuropathology of major depressive disorder.