REVENTION IS A GOAL TO WHICH every field of medicine aspires because it reduces morbidity, may alleviate suffering, and reduces the cost of health care. Although the Commission on Chronic Illness proposed the classification of primary, secondary, and tertiary prevention 1 in 1957, the Institute of Medicine Committee on Prevention of Mental Disorders recommended a new terminology 2 in 1995. According to the new terminology, preventive intervention is defined as an intervention before the patient receives a diagnosis. Alternatively, treatment is an intervention for patients already with a diagnosis, and maintenance is the care of patients with chronic illnesses including relapse prevention. Furthermore, preventive interventions are categorized as (1) indicated, addressing high-risk individuals with premorbid signs or symptoms; (2) selective, for select individuals with demonstrated increased risk of developing illness; and (3) universal, for a whole population in a group with all levels of risk. Although the ultimate goal of preventive intervention in mental disorders is universal, the major problem is See also Patient Page.

Effect sizes (ES) tell the magnitude of the difference between treatments and, ideally, should tell clinicians how likely their patients will benefit from the treatment. Currently used ES are expressed in statistical rather than in clinically useful terms and may not give clinicians the appropriate information. We restrict our discussion to studies with two groups: one with n patients receiving a new treatment and the other with m patients receiving the usual or no treatment. The standardized mean difference (e.g. Cohen's d) is a well-known index for continuous outcomes. There is some intuitive value to d, but measuring improvement in standard deviations (SD) is a statistical concept that may not help a clinician. How much improvement is a half SD? A more intuitive and simple-to-calculate ES is the probability that the response of a patient given the new treatment (X) is better than the one for a randomly chosen patient given the old or no treatment (Y) (i.e. P(X > Y), larger values meaning better outcomes). This probability has an immediate identity with the area under the curve (AUC) measure in procedures for receiver operator characteristic (ROC) curve comparing responses to two treatments. It also can be easily calculated from the Mann-Whitney U, Wilcoxon, or Kendall tau statistics. We describe the characteristics of an ideal ES. We propose P(X > Y) as an alternative index, summarize its correspondence with well-known non-parametric statistics, compare it to the standardized mean difference index, and illustrate with clinical data.

ehaviors related to self-regulation, such as substance use disorders or antisocial behaviors, have far-reaching consequences for affected individuals, their families, communities and society at large 1,2 . Collectively, this group of correlated traits are classified as externalizing 3 . Twin studies have demonstrated that externalizing liability is highly heritable (~80%) 4,5 . To date, however, no large-scale molecular genetic studies have utilized the extensive degree of genetic overlap among externalizing traits to aid gene discovery, as most studies have focused on individual disorders 6 . For many high-cost, high-risk behaviors with an externalizing component-opioid use disorder and suicide attempts 7 being salient examples-there are limited genotyped cases available for gene discovery 8,9 .A complementary strategy to the single-disease approach is to study the shared genetic architecture across traits in multivariate analyses, which boosts statistical power by pooling data across

Objective It has been estimated that 10%–20% of U.S. veterans of the wars in Iraq and Afghanistan experienced mild traumatic brain injury (TBI), mostly secondary to blast exposure. Diffusion tensor imaging (DTI) may detect subtle white matter changes in both the acute and chronic stages of mild TBI and thus has the potential to detect white matter damage in patients with TBI. The authors used DTI to examine white matter integrity in a relatively large group of veterans with a history of mild TBI. Method DTI images from 72 veterans of the wars in Iraq and Afghanistan who had mild TBI were compared with DTI images from 21 veterans with no exposure to TBI during deployment. Conventional voxel-based analysis as well as a method of identifying spatially heterogeneous areas of decreased fractional anisotropy (“potholes”) were used. Veterans also underwent psychiatric and neuropsychological assessments. Results Voxel-based analysis did not reveal differences in DTI parameters between the veterans with mild TBI and those with no TBI. However, the veterans with mild TBI had a significantly higher number of potholes than those without TBI. The difference in the number of potholes was not influenced by age, time since trauma, a history of mild TBI unrelated to deployment, or coexisting psychopathology. The number of potholes was correlated with the severity of TBI and with performance in executive functioning tasks. Conclusions Veterans who had blast-related mild TBI showed evidence of multifocal white matter abnormalities that were associated with severity of the injury and with relevant functional measures. Overall, white matter potholes may constitute a sensitive biomarker of axonal injury that can be identified in mild TBI at acute and chronic stages of its clinical course.

To our knowledge, this is the first controlled trial that demonstrates the efficacy of rTMS among geriatric patients with VD. Older age and smaller frontal gray matter volumes were associated with a poorer response to rTMS.

Objective The aim of this study was to investigate the prevalence of clinical and laboratory metabolic abnormalities during long-term risperidone treatment in children and adolescents. Methods Medically healthy 7- to 17-year-old children chronically treated, in a naturalistic setting, with risperidone were recruited through child psychiatry clinics. Anthropometric measurements and laboratory testing were conducted. Developmental and medication histories were obtained from medical records. Results In 99 patients treated with risperidone for an average of 2.9 years, a significant increase in age- and gender-adjusted weight and body mass index (BMI) (i.e., z-scores) was observed. Concomitant treatment with psychostimulants did not attenuate this weight gain. Risperidone-associated weight gain was negatively correlated with the BMI z-score obtained at the onset of risperidone treatment. Compared to lean children, overweight and obese children had higher odds of metabolic abnormalities, including increased waist circumference, hypertriglyceridemia, and low high-density lipoprotein cholesterol (HDL-C). They also tended to have a higher insulin level and homeostasis model assessment insulin resistance (HOMA-IR) index. As a result, upon recruitment in the study, children with excessive weight were 12 times more likely to have at least one laboratory metabolic abnormality and seven times more likely to have at least one criterion of the metabolic syndrome compared to lean subjects. In contrast to excessive weight status, gaining ≥0.5 BMI z-score point during risperidone treatment was not associated with a significantly higher occurrence of metabolic disturbances. Conclusions The long-term use of risperidone, especially when weight is above normal, is associated with a number of metabolic abnormalities but a low prevalence of the metabolic syndrome phenotype. Future studies should evaluate the stability of these abnormalities over time.

Context Adjunctive restorative therapies administered during the first few months after stroke, the period with the greatest degree of spontaneous recovery, reduce the number of stroke patients with significant disability. Objective To examine the effect of escitalopram on cognitive outcome. We hypothesized that patients who received escitalopram would show improved performance in neuropsychological tests assessing memory and executive functions than patients who received placebo or underwent Problem Solving Therapy. Design Randomized trial. Setting Stroke center. Participants One hundred twenty-nine patients were treated within 3 months following stroke. The 12-month trial included 3 arms: a double-blind placebo-controlled comparison of escitalopram (n=43) with placebo (n=45), and a nonblinded arm of Problem Solving Therapy (n=41). Outcome Measures Change in scores from baseline to the end of treatment for the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) and Trail-Making, Controlled Oral Word Association, Wechsler Adult Intelligence Scale–III Similarities, and Stroop tests. Results We found a difference among the 3 treatment groups in change in RBANS total score (P<.01) and RBANS delayed memory score (P<.01). After adjusting for possible confounders, there was a significant effect of escitalopram treatment on the change in RBANS total score (P<.01, adjusted mean change in score: escitalopram group, 10.0; nonescitalopram group, 3.1) and the change in RBANS delayed memory score (P<.01, adjusted mean change in score: escitalopram group, 11.3; nonescitalopram group, 2.5). We did not observe treatment effects in other neuropsychological measures. Conclusions When compared with patients who received placebo or underwent Problem Solving Therapy, stroke patients who received escitalopram showed improvement in global cognitive functioning, specifically in verbal and visual memory functions. This beneficial effect of escitalopram was independent of its effect on depression. The utility of antidepressants in the process of poststroke recovery should be further investigated. Trial Registration clinicaltrials.gov Identifier: NCT00071643

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