The Canadian Journal of Psychiatry

To review the findings of structural and functional neuroimaging studies in attention-deficit hyperactivity disorder (ADHD), with a focus on abnormalities reported in brain regions that lie outside the frontostriatal circuitry, which is currently believed to play a central role in the pathophysiology of ADHD.

Relevant publications were found primarily by searching the MEDLINE and PubMed databases using the keywords ADHD and the abbreviations of magnetic resonance imaging (MRI), functional MRI, positron emission tomography, and single photon emission computed tomography. The reference lists of the articles found through the databases were then reviewed for the purpose of finding additional articles.

There is now substantial evidence of structural and functional alterations in regions outside the frontostriatal circuitry in ADHD, most notably in the cerebellum and the parietal lobes.

Although there is compelling evidence suggesting that frontostriatal dysfunction may be central to the pathophysiology of ADHD, the neuroimaging findings point to distributed neural substrates rather than a single one. More research is needed to elucidate the nature of contributions of nonfrontostriatal regions to the pathophysiology of ADHD.

To highlight recent advances in the conceptualization of attention-deficit hyperactivity disorder (ADHD) emerging from neuroimaging and endophenotypic approaches.

We selectively reviewed recent published literature on the phenomena of resting-state functional connectivity, intrasubject variability, and diffusion tensor imaging pertaining to ADHD.

Recent advances based on the novel approach of resting-state functional connectivity appear to be highly promising and likely to link to studies of intrasubject variability.

Endophenotypic fractionation may offer a means of addressing the complex heterogeneity of ADHD on the path to testable models of pathophysiology. Such models focusing on intrasubject variability, intrinsic brain activity, and reward-related processing are progressing rapidly.

To examine the prevalence of comorbid Axis I (current and lifetime) and II disorders in adult men and women with attention-deficit hyperactivity disorder (ADHD).

Adult patients (n = 447; 266 men, 181 women) received comprehensive assessments for ADHD and Axis I and II disorders. Adults were aged between 17 and 74 years. Among the patients diagnosed with ADHD (n = 335), there were those with ADHD inattentive subtype (ADHD-I) (n = 199), hyperactive–impulsive subtype (ADHD-H) (n = 24), or combined ADHD subtype (ADHD-C) (n = 112). Chi-square and logistic regression analyses were performed to examine associations between adults with and without ADHD on Axis I and II disorders.

Adults with ADHD, compared with those without ADHD, had higher rates of Axis I (46.9% and 27.31%) and Axis II (50.7% and 38.2%) disorders. Adults with ADHD-C were more likely to have mood disorder, anxiety, conduct disorder, and substance use disorder as well as obsessive–compulsive personality disorder, passive–aggressive personality disorder, depressive personality disorder, narcissistic personality disorder, and borderline personality disorder (BPD).

Men with ADHD were more likely to have antisocial personality disorder and had higher rates of current drug abuse than women with ADHD. Women with ADHD had higher rates of past and current panic disorder, and past anorexia and bulimia. Women with ADHD were more likely to have BPD than men with ADHD.

Adults with ADHD have very high rates of comorbid Axis I and II disorders, with differences found between men and women on certain comorbid disorders.

Research has demonstrated that impulsivity is strongly associated with suicide-related ideation and behaviour among young adults. However, to date, the potential importance of impulsivity as a predictor of suicide-related ideation in later life has yet to be determined. Our study examined impulsivity, hopelessness, depressive symptomatology, and sociodemographic factors vis-à-vis suicide-related ideation among older adults at risk of self-harm.

A sample (n = 117) of older adults was recruited from multiple sources for this study over a 1-year period. Suicide-related ideation was measured with the Geriatric Suicide Ideation Scale, a multidimensional measure of suicide-related ideation developed for use with older adults.

Canonical correlation identified 2 pairings of linear composites in which impulsivity emerged along both as significantly associated with facets of suicide-related ideation. Of note, the greater proportion of variance in impulsivity was subsumed along the second set of vectors with somatic depressive symptoms.

Our findings suggest that the impulse to self-harm may be even more pronounced among older adults less likely to present as typically depressed. It is further suggested that impulsivity is more broadly associated with suicide-related ideation than hopelessness, and that screening for impulsivity as well as hopelessness may increase clinicians' ability to identify older adults at greatest risk of self-harm.

To assess the impact on knowledge and attitudes of a tailored educational intervention on depression using a modified version of the Prochaska stages of change model, compared with standard continuing medical education, for general practitioners (GPs) in primary care in Iran.

Using a randomized controlled trial, a total of 192 GPs were evenly randomized to intervention or control arm. The topic for the educational intervention was depressive disorders. The participants were divided in to small and large groups, depending on their initial stage of change. The GPs' knowledge and skills regarding management of depressive disorders were assessed through a questionnaire with 7 multiple choice questions, 11 Likert statements, 3 case vignettes, and 1 essay question. Attitudes toward management of depressive disorders were also assessed. Both questionnaires were validated.

There was a significant improvement in knowledge mean scores regarding multiple choice and Likert questions (intervention effect 6%; P = 0.002), as well as for the case vignettes and essay question (intervention effect 12%; P = 0.011) in the intervention arm, in comparison with the control arm. There were significant changes in mean attitude scores in both study arms, but no difference between them.

A theoretical model of medical learning and behavioural change can be used to devise educational formats that suit different stages of learning. Such tailored educational formats can improve GPs' knowledge and skills regarding management of depressive disorders.

To compare the prevalence, risk factors, and use of care for depression between 2 periods, concerning changes in social factors and health care provision.

We compared data from 2 surveys carried out in a large urbanized French region (Île-de-France) 15 years apart (1991, n = 1192; 2005, n = 5308), using comparable methodology and tools.

The overall prevalence of depression has slightly increased over this period. In contrast, the tendency of people who claim they feel depressed has dramatically increased. At-risk populations have also changed during this period. The proportion of people consulting a psychiatrist for depression has not changed, while general practitioner (GP) consultations have decreased and psychologist consultations have increased 3-fold. Psychotropic use by people who are depressed has decreased significantly.

The trend toward increased depressive symptoms does not correspond to an increase in depressed disorders. In a well-staffed urbanized French region, psychologists are playing a growing role in managing depression at the expense of GPs, when the use of a psychiatrist remains unchanged; decreased use of psychotropic drugs may be a consequence.

To investigate predictors of adherence with a cognitive-behavioural intervention in first-episode psychosis (FEP) patients.

Predictors of adherence to cognitive-behavioural therapy (CBT) were longitudinally investigated in the experimental arm of a randomized controlled trial designed to evaluate the effectiveness of a CBT intervention for relapse prevention early in the course of psychosis when compared with treatment as usual within 2 high quality, youth oriented, specialist FEP programs (the EPISODE II trial).

Longer duration of untreated psychosis (DUP) and poorer level of insight predicted poor adherence to CBT. This association remained significant after controlling for potential confounders.

Treatment delay may decrease adherence with CBT in FEP patients. Reducing DUP and promoting insight early in the course of psychosis are likely to enhance adherence with CBT.