Letters
effect of including male-type symptoms on sex differences in depression was informed by existing empirical measures, clinical reports, and popular claims suggesting that symptoms not included in the DSM-IV (or DSM-5) definition of depression (eg, irritability and anger) may be particularly important for identifying depression in men. While we do not propose that any particular symptoms are exclusive to men’s presentation of depression, we agree with Addis’ Gendered Responding Framework1 that differences in the way men’s and women’s responses to depressed mood and negative effect (eg, rumination, distraction, and avoidance) need to be considered in the application of diagnostic criteria for depression. We fully recognize that our findings must be considered in the context of some important limitations, which are clearly identified in our article. Because our report used secondary data analysis, we were constrained by question availability and wording and the timeframes that were present in the data set. This is one of the reasons why we explicitly stated that we do not recommend using either the Male Symptoms Scale or the Gender Inclusive Depression Scale from our study in the future.3 Our investigation was not intended to produce a definitive list of depression symptoms that distinguished depression in men and women, but instead it was evidence that supports a growing consensus that men’s and women’s experiences of depression may include presentations that are different from current diagnostic criteria. Finally, the application of DSM criteria was made using highly structured questionnaires administered as part of a survey, which limited the ability to weigh the differential importance of various symptoms in making a diagnosis within the context of gender. Understanding the relationship between clinical diagnosis and questionnaire administration in the application of diagnostic criteria is a challenge that will be addressed in psychiatric epidemiology for many years. An important finding from our article is that symptoms typically designated as male type are fairly common in women. While women had a higher rate of irritability, men had a higher rate of reporting anger attacks/aggression, and both irritability and anger attacks were endorsed at extremely high rates in both groups. Using our alternative criteria, both sexes had very similar symptom profiles when it came to which symptoms were endorsed the most, with men and women endorsing the same top 5 symptoms. Future studies should explore whether an expanded set of depression criteria, with a similar timeframe of symptoms, yields similar findings to our study. Ultimately, we need to more accurately identify people who need mental health treatment. Given the complex heterogeneity involved in symptom presentation by men and women, more research is needed on the ability of highly structured questionnaires to accomplish that difficult task. Lisa A. Martin, PhD Harold W. Neighbors, PhD Derek M. Griffith, PhD
Conflict of Interest Disclosures: None reported. 1. Addis ME. Gender and depression in men. Clin Psychol Sci Pract. 2008;15(3):153-168. doi:10.1111/j.1468-2850.2008.00125.x. 2. Nolen-Hoeksema S. It is not what you have; it is what you do with it: support for Addis’s Gendered Responding Framework. Clin Psychol Sci Pract. 2008;15(3):178-181. doi:10.1111/j.1468-2850.2008.00128.x. 3. Martin LA, Neighbors HW, Griffith DM. The experience of symptoms of depression in men vs women: analysis of the National Comorbidity Survey Replication. JAMA Psychiatry. 2013;70(10):1100-1106.
Prescription Opioid Dependence: The Clinical Challenge To the Editor In an article in JAMA Psychiatry, Sigmon and colleagues1 concluded that their findings “suggest that a meaningful subset of [prescription opioid]–dependent outpatients may respond positively to a 4-week taper plus naltrexone maintenance intervention.” It would seem this is an overly positive assessment. First, the number of participants was very small; the best outcomes were achieved with just 22 individuals assigned to the 4-week taper group. Furthermore, the best was not particularly good since half of these individuals had relapsed to nonprescribed opioid use 4 weeks after detoxification was completed and before naltrexone maintenance could be initiated. Because opioid dependence is recognized as a chronic condition, the outcome beyond the 8 weeks of this trial would presumably be very substantially worse. The trial seemed merely to confirm what has been known for decades: when treatment of opioid dependence ends, relapse is the rule rather than the exception, and this reality applies regardless of the duration of detoxification or associated medical or psychosocial support that is offered. It is this stark reality that must be conveyed to those seeking care, along with the fact that, as the authors acknowledge, “agonist maintenance is the recommended treatment for most opioiddependent patients.” The challenge is not to determine which detoxification schedule is a bit better than another, but to ensure access to long-term treatment that so many dependent individuals want and need—and without which many will die. Robert G. Newman, MD, MPH Author Affiliation: Beth Israel Medical Center, New York, New York (Newman). Corresponding Author: Robert G. Newman, MD, MPH, 605 E 82nd St, New York, NY 10028 ([email protected]). Conflict of Interest Disclosures: None reported. 1. Sigmon SC, Dunn KE, Saulsgiver K, et al. A randomized, double-blind evaluation of buprenorphine taper duration in primary prescription opioid abusers. JAMA Psychiatry. 70(12):1347-1354.
The Problem of Spurious Correlations Between Pairs of Brain Metabolite Values Measured in the Same Voxel With Magnetic Resonance Spectroscopy
Author Affiliations: University of Michigan, Dearborn (Martin); The Institute of Social Research, Program for Research on Black Americans, Research Center for Group Dynamics, University of Michigan, Ann Arbor (Neighbors); Center for Medicine, Health, and Society, Vanderbilt University, Nashville, Tennessee (Griffith).
338
Corresponding Author: Derek M. Griffith, PhD, Vanderbilt University, Center for Medicine, Health and Society, 2301 Vanderbilt Pl, PMB 351665, Nashville, TN 37235-1665 ([email protected]).
To the Editor The article by Kraguljac and colleagues1 presents a potentially important finding on the association between hippocampal glutamate levels and hippocampal morphology. However, one aspect of the article requires correction. The au-
JAMA Psychiatry March 2014 Volume 71, Number 3
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: by a University of Florida User on 11/27/2017
jamapsychiatry.com
effect of including male-type symptoms on sex differences in depression was informed by existing empirical measures, clinical reports, and popular claims suggesting that symptoms not included in the DSM-IV (or DSM-5) definition of depression (eg, irritability and anger) may be particularly important for identifying depression in men. While we do not propose that any particular symptoms are exclusive to men’s presentation of depression, we agree with Addis’ Gendered Responding Framework1 that differences in the way men’s and women’s responses to depressed mood and negative effect (eg, rumination, distraction, and avoidance) need to be considered in the application of diagnostic criteria for depression. We fully recognize that our findings must be considered in the context of some important limitations, which are clearly identified in our article. Because our report used secondary data analysis, we were constrained by question availability and wording and the timeframes that were present in the data set. This is one of the reasons why we explicitly stated that we do not recommend using either the Male Symptoms Scale or the Gender Inclusive Depression Scale from our study in the future.3 Our investigation was not intended to produce a definitive list of depression symptoms that distinguished depression in men and women, but instead it was evidence that supports a growing consensus that men’s and women’s experiences of depression may include presentations that are different from current diagnostic criteria. Finally, the application of DSM criteria was made using highly structured questionnaires administered as part of a survey, which limited the ability to weigh the differential importance of various symptoms in making a diagnosis within the context of gender. Understanding the relationship between clinical diagnosis and questionnaire administration in the application of diagnostic criteria is a challenge that will be addressed in psychiatric epidemiology for many years. An important finding from our article is that symptoms typically designated as male type are fairly common in women. While women had a higher rate of irritability, men had a higher rate of reporting anger attacks/aggression, and both irritability and anger attacks were endorsed at extremely high rates in both groups. Using our alternative criteria, both sexes had very similar symptom profiles when it came to which symptoms were endorsed the most, with men and women endorsing the same top 5 symptoms. Future studies should explore whether an expanded set of depression criteria, with a similar timeframe of symptoms, yields similar findings to our study. Ultimately, we need to more accurately identify people who need mental health treatment. Given the complex heterogeneity involved in symptom presentation by men and women, more research is needed on the ability of highly structured questionnaires to accomplish that difficult task. Lisa A. Martin, PhD Harold W. Neighbors, PhD Derek M. Griffith, PhD
Conflict of Interest Disclosures: None reported. 1. Addis ME. Gender and depression in men. Clin Psychol Sci Pract. 2008;15(3):153-168. doi:10.1111/j.1468-2850.2008.00125.x. 2. Nolen-Hoeksema S. It is not what you have; it is what you do with it: support for Addis’s Gendered Responding Framework. Clin Psychol Sci Pract. 2008;15(3):178-181. doi:10.1111/j.1468-2850.2008.00128.x. 3. Martin LA, Neighbors HW, Griffith DM. The experience of symptoms of depression in men vs women: analysis of the National Comorbidity Survey Replication. JAMA Psychiatry. 2013;70(10):1100-1106.
Prescription Opioid Dependence: The Clinical Challenge To the Editor In an article in JAMA Psychiatry, Sigmon and colleagues1 concluded that their findings “suggest that a meaningful subset of [prescription opioid]–dependent outpatients may respond positively to a 4-week taper plus naltrexone maintenance intervention.” It would seem this is an overly positive assessment. First, the number of participants was very small; the best outcomes were achieved with just 22 individuals assigned to the 4-week taper group. Furthermore, the best was not particularly good since half of these individuals had relapsed to nonprescribed opioid use 4 weeks after detoxification was completed and before naltrexone maintenance could be initiated. Because opioid dependence is recognized as a chronic condition, the outcome beyond the 8 weeks of this trial would presumably be very substantially worse. The trial seemed merely to confirm what has been known for decades: when treatment of opioid dependence ends, relapse is the rule rather than the exception, and this reality applies regardless of the duration of detoxification or associated medical or psychosocial support that is offered. It is this stark reality that must be conveyed to those seeking care, along with the fact that, as the authors acknowledge, “agonist maintenance is the recommended treatment for most opioiddependent patients.” The challenge is not to determine which detoxification schedule is a bit better than another, but to ensure access to long-term treatment that so many dependent individuals want and need—and without which many will die. Robert G. Newman, MD, MPH Author Affiliation: Beth Israel Medical Center, New York, New York (Newman). Corresponding Author: Robert G. Newman, MD, MPH, 605 E 82nd St, New York, NY 10028 ([email protected]). Conflict of Interest Disclosures: None reported. 1. Sigmon SC, Dunn KE, Saulsgiver K, et al. A randomized, double-blind evaluation of buprenorphine taper duration in primary prescription opioid abusers. JAMA Psychiatry. 70(12):1347-1354.
The Problem of Spurious Correlations Between Pairs of Brain Metabolite Values Measured in the Same Voxel With Magnetic Resonance Spectroscopy
Author Affiliations: University of Michigan, Dearborn (Martin); The Institute of Social Research, Program for Research on Black Americans, Research Center for Group Dynamics, University of Michigan, Ann Arbor (Neighbors); Center for Medicine, Health, and Society, Vanderbilt University, Nashville, Tennessee (Griffith).
338
Corresponding Author: Derek M. Griffith, PhD, Vanderbilt University, Center for Medicine, Health and Society, 2301 Vanderbilt Pl, PMB 351665, Nashville, TN 37235-1665 ([email protected]).
To the Editor The article by Kraguljac and colleagues1 presents a potentially important finding on the association between hippocampal glutamate levels and hippocampal morphology. However, one aspect of the article requires correction. The au-
JAMA Psychiatry March 2014 Volume 71, Number 3
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: by a University of Florida User on 11/27/2017
jamapsychiatry.com
