Personality disorders and nonfatal unintentional injuries among US adults.

OBJECTIVE: To investigate the association between personality disorders and nonfatal unintentional injuries in a representative sample of US adults. METHODS: Data on self-reported nonfatal unintentional injuries during the 12 months before the interview were obtained from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) were analyzed; 43,093 adults > or = 18 years participated in the NESARC wave I survey in 2001-02. Personality disorders were determined using the NIAAA Alcohol Use Disorders and Associated Disabilities Interview Schedule-DSM-IV. RESULTS: Individuals with at least one personality disorder had a significantly higher 12-month incidence of injuries than people without any personality disorder (p<0.001). After accounting for sociodemographic characteristics or other mental disorders, OR was 1.54 (95% CI 1.39 to 1.71) for individuals with one personality disorder and 1.80 (95% CI 1.58 to 2.05) for individuals with two or more personality disorders compared with people with no personality disorder. CONCLUSION: Personality disorders were associated with a significantly increased risk of unintentional injuries. This information has important implications for the treatment of patients with these disorders.

Improving mental health care transitions for children and youth: a protocol to implement and evaluate an emergency department clinical pathway.

BACKGROUND: While the emergency department (ED) is often a first point of entry for children and youth with mental health (MH) concerns, there is a limited capacity to respond to MH needs in this setting. Child MH systems are typically fragmented among multiple ministries, organizations, and providers. Communication among these groups is often poor, resulting in gaps, particularly in transitions of care, for this vulnerable population. The evidence-based Emergency Department Mental Health Clinical Pathway (EDMHCP) was created with two main goals: (1) to guide risk assessment and disposition decision-making for children and youth presenting to the ED with MH concerns and (2) to provide a streamlined transition to follow-up services with community MH agencies (CMHAs) and other providers. The purpose of this paper is to describe our study protocol to implement and evaluate the EDMHCP. METHODS/DESIGN: This mixed methods health services research project will involve implementation and evaluation of the EDMHCP in four exemplar ED-CMHA dyads. The Theoretical Domains Framework will be used to develop a tailored intervention strategy to implement the EDMHCP. A multiple baseline study design and interrupted time-series analysis will be used to determine if the EDMHCP has improved health care utilization, medical management of the MH problems, and health sector coordination. The primary process outcome will be the proportion of patients with MH-specific recommendations documented in the health record. The primary service outcome will be the proportion of patients receiving the EDMHCP-recommended follow-up at 24-h or at 7 days. Data sources will include qualitative interviews, health record audits, administrative databases, and patient surveys. A concurrent process evaluation will be conducted to assess the degree of variability and fidelity in implementation across the sites. DISCUSSION: This paper presents a novel model for measuring the effects of the EDMHCP. Our development process will identify how the EDMHCP is best implemented among partner organizations to deliver evidence-based risk management of children and youth presenting with MH concerns. More broadly, it will contribute to the body of evidence supporting clinical pathway implementation within novel partnerships. TRIAL REGISTRATION: ClinicalTrials.gov ( NCT02590302 ).

Decreased cortisol levels in adolescent girls with conduct disorder.

BACKGROUND: Female adolescent antisocial behavior is increasing, but little is known about the neuroendocrinologic aspects of this disorder. On the basis of reports of decreased cortisol levels in antisocial males, we investigated morning plasma cortisol levels in adolescent girls with conduct disorder (CD). METHODS: Three plasma samples for cortisol levels were taken every 20 minutes between 8 and 9 AM in 47 adolescent girls with CD (mean +/- SD age, 16.5 +/- 0.9 years) and 37 normal control girls (mean age, 16.0 +/- 0.8 years). All blood was drawn within 72 hours after the onset of menstrual flow. RESULTS: Girls with CD had significantly lower cortisol levels than girls in the normal control group at all 3 sampling times. This finding was not due to procedural factors, demographic characteristics, or the use of medications. The girls with CD who had no other psychiatric problems had lower cortisol levels than girls with other disorders or those in the normal control group. In the multiple regression analysis, having CD predicted 10% of the variance in cortisol levels. CONCLUSIONS: Morning plasma cortisol levels were significantly diminished in adolescent girls with CD. Decreased cortisol levels appear to be most strongly associated with antisocial girls who do not have other psychiatric disorders.

What happens to "bad" girls? A review of the adult outcomes of antisocial adolescent girls.

OBJECTIVE: The purpose of this article is to review critically the data on the adult outcomes of adolescent girls with antisocial behavior. METHOD: Five literature databases were searched for studies on the adult outcomes of girls with either conduct disorder or delinquency. RESULTS: Twenty studies met the inclusion criteria. As adults, antisocial girls manifested increased mortality rates, a 10- to 40-fold increase in the rate of criminality, substantial rates of psychiatric morbidity, dysfunctional and often violent relationships, and high rates of multiple service utilization. Possible explanations for these findings include a pervasive biological or psychological deficit or baseline heterogeneity in the population of antisocial girls. CONCLUSIONS: This review establishes that female adolescent antisocial behavior has important long-term individual and societal consequences. At present, there are insufficient data to enable us to prevent these outcomes or treat them if they occur. Future research should include cross-sectional studies detailing the phenomenology of female antisocial behavior and longitudinal investigations that not only track development into adulthood but also explore the role of potential modifying variables such as prefrontal lobe dysfunction and psychiatric comorbidity.

New strategies in the treatment of depression in women.

It is well documented that women are twice as likely as men to be diagnosed with depression, but recent data suggest that gender differences also must be considered in the treatment of depressed patients. Specifically, depression in women may have a different longitudinal course and has been associated with a less successful treatment outcome. Several possible explanations are explored here. First, there appear to be gender differences in pharmacokinetics and responsiveness to medication. Second, depressed women have higher rates of psychiatric and medical comorbidity than depressed men. Third, normal hormonal changes may serve as triggers for psychiatric illness in genetically vulnerable women. Finally, women are subject to unique psychosocial stressors that can impede recovery if not addressed. These data indicate that our approaches to treating women with depression need to be modified. This report concludes with a list of integrated strategies designed to meet the treatment needs of these patients.

Reflections on stillness: mothers' reactions to the still-face situation.

The still-face procedure, in which mothers maintain a neutral face and are noninteractive with their infants, has been used to study the effects of maternal withdrawal on the mother-infant interaction. In this study, 56 mothers' reactions to their own experience during a still-face procedure were explored using an open-ended interview. The associations between the mothers' reported experience, the infants' behavior during the procedure, and the mothers' behavior during subsequent play were examined. Over half of the mothers reported experiencing discomfort during the session and were more likely to report discomfort if their infants protested their affective absence. Mothers reporting discomfort were significantly more likely to pick up their infants and continue to reflect verbally on their own feelings after the still-face ended. These results are discussed in terms of their clinical implications for understanding the early development of the social dialogue between mother and infant.

Discovery of blood transcriptomic markers for depression in animal models and pilot validation in subjects with early-onset major depression.

Early-onset major depressive disorder (MDD) is a serious and prevalent psychiatric illness in adolescents and young adults. Current treatments are not optimally effective. Biological markers of early-onset MDD could increase diagnostic specificity, but no such biomarker exists. Our innovative approach to biomarker discovery for early-onset MDD combined results from genome-wide transcriptomic profiles in the blood of two animal models of depression, representing the genetic and the environmental, stress-related, etiology of MDD. We carried out unbiased analyses of this combined set of 26 candidate blood transcriptomic markers in a sample of 15-19-year-old subjects with MDD (N=14) and subjects with no disorder (ND, N=14). A panel of 11 blood markers differentiated participants with early-onset MDD from the ND group. Additionally, a separate but partially overlapping panel of 18 transcripts distinguished subjects with MDD with or without comorbid anxiety. Four transcripts, discovered from the chronic stress animal model, correlated with maltreatment scores in youths. These pilot data suggest that our approach can lead to clinically valid diagnostic panels of blood transcripts for early-onset MDD, which could reduce diagnostic heterogeneity in this population and has the potential to advance individualized treatment strategies.

The role of dyadic affect in play and infant sex in predicting infant response to the still-face situation.

This study was designed to examine mothers' and 3-month-old infants' affect in play and infant sex as predictors of infants' response to the still-face situation. Infants who evidenced negative affect in play were likely to respond with negative displays during a subsequent still-face situation. Maternal positivity in play was positively correlated with infants' social gaze in the still-face situation. In addition, maternal positivity and infant sex significantly interacted in predicting infant affective response in the still-face situation. For girls, maternal positivity was associated with decreased expressivity. For boys, maternal positivity was associated with early positive bids, which were followed by negative bids and moderately negative affect. Finally, maternal positivity and its interaction with infant sex provide unique information beyond the carry-over effect from infant affect in play to infant response to the still-face. Results are discussed in terms of patterns of individual and joint regulation.

Comparison of inhibitory actions of chlorpromazine or its 7,8-dihydroxy and 7,8-dioxo-didesmethyl analogs on DA-sensitive adenylate cyclase and calmodulin activation of phosphodiesterase in rat striatum.

Two chlorpromazine analogs, 7,8-diOH- and 7,8-dioxo-didesmethyl-chlorpromazine were compared to chlorpromazine (CPZ) with regard to inhibition of three parameters of enzyme activity in rat striatum: 1) dopamine + GTP-sensitive adenylate cyclase in homogenates; 2) dopamine, GTP, calmodulin and Ca++-sensitive adenylate cyclase in washed particulate fractions; and 3) calmodulin-Ca++ activation of high Km cyclic AMP dependent phosphodiesterase in dialyzed supernatant fractions. Chlorpromazine was clearly the most potent antagonist in all three experimental conditions. The CPZ derivatives displayed greatest potency on the particulate adenylate cyclase and all three drugs were 1 to 2 orders of magnitude more effective as inhibitors of the adenylate cyclase preparations than with the calmodulin-Ca++ phosphodiesterase.

Neuropsychiatric side effects of FK506 vs. cyclosporine A. First-week postoperative findings.

The authors studied 31 liver transplant patients to compare neuropsychiatric side effects of a newer immunosuppressant, FK506, to cyclosporine A (CYA). Patients were randomly assigned to either FK506 or CYA. At the 1-week postoperative stage, cognitive status was assessed with the Mini-Mental State Exam, Trailmaking Tests (TMT) A and B, Delirium Rating Scale, and a neuropsychiatric symptom checklist. No statistically significant differences were found on any outcome variable between these two drugs, though scores on the TMTs were impaired as compared with published norms. The FK506 patients had moderately impaired TMT scores, whereas the CYA patients had only mild impairment. The patients demonstrate good cognitive recovery at 1 week post-transplantation, with only mild evidence of cognitive impairment.

Primary care clinicians' use of standardized psychiatric diagnoses.

OBJECTIVE: Treatment of child mental health (MH) problems should be informed by psychiatric diagnosis. Whether primary care clinicians (PCCs) use standardized psychiatric diagnostic criteria to direct the treatment of child MH problems is unknown. This study investigated PCCs' use of Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria during office visits. METHODS: The data were obtained from 3674 children ages 4-15 years who were recognized as having one or more MH problems during office visits by clinicians participating in the Child Behaviour Study. Parents completed questionnaires before seeing the clinician. Clinicians completed a survey after the visit. The primary outcome was whether PCCs used standardized criteria to generate a diagnosis for children with recognized MH problems. RESULTS: Clinicians used DSM criteria in 23% of visits in which a psychosocial problem was recognized, and 57% of PCCs reported no use of DSM. DSM criteria were used most frequently (38% of visits) when PCCs reported attention problems. Medications were much more likely to be prescribed during visits when PCCs diagnosed using DSM criteria (63% of visits vs. 19% when criteria were not used). However, only 51% of psychotropic medication prescriptions were based on a DSM diagnosis. CONCLUSIONS: Clinicians used standardized criteria infrequently, and primarily to diagnose attention problems.

Attenuation of catecholamine-coupled adenylate cyclase following surgical isolation of rat caudate.

Six weeks following complete unilateral surgical isolation of the rat caudate nucleus, activation of adenylate cyclase was reduced in response to dopamine (DA), norepinephrine (NE), 5' -guanylyl-imidodiphosphate [Gpp(NH)p], DA + Gpp(NH)p, and NaF. The low Km form of cyclic AMP phosphodiesterase was elevated in the isolated side when compared to the intact caudate. No changes in activities of guanylate cyclase or in high Km cyclic AMP phosphodiesterase (with or without the calcium-dependent regulator protein, calmodulin or CDR) were observed between the control and isolated caudate. Histologically, the neural damage to the isolated caudate was principally confined to reduced numbers of dendritic spines of the remaining intrinsic caudate neurons.

Serum indole-3-acetic acid in control subjects and newly abstinent alcoholics after an oral loading with L-tryptophan: a preliminary study using liquid chromatography with amperometric detection.

Described in this paper is a rapid, isocratic assay for serum indole-3-acetic acid (IAA). The sample preparation involves only protein precipitation using sulfosalicylic acid, and the sensitivity of amperometric detection is in the picogram range. The chromatographic analysis time is approximately 4 min. The devised method was used for a longitudinal study of IAA levels in serum samples from control subjects and newly abstinent alcoholics. Dietary variations were eliminated by administering a 2.0-g loading dose of L-Trp to all subjects investigated. The results are presented in the form of cumulative frequency polygons. Preliminary data indicate no differences in IAA levels between newly abstinent alcoholics and control subjects.

Schizophrenia and the life cycle.

We reframe the longitudinal treatment of persons with schizophrenia from the perspective of phases in adult development. This approach articulates the need for different interventions of varying intensities over the person's lifetime. The paper discusses the implications of an adult developmental perspective in managing pharmacologic treatment and psychosocial interventions, and in reallocating financial resources for improved long-term outcomes. This perspective is especially useful in the context of a comprehensive community mental health program permitting access to a continuum of services throughout the lifecycle.

Primary care treatment of pediatric psychosocial problems: A study from pediatric research in office settings and ambulatory sentinel practice network.

OBJECTIVE: Psychosocial problems cause much of the morbidity among children, and their frequency of presentation in primary care is growing. How is primary care treatment of children's psychosocial problems affected by child symptoms, physician training, practice structure, insurance, physician/patient relationship, and family demographics? DESIGN: Questionnaire study of treatment of psychosocial problems during office visits by children. SETTINGS: At total of 401 primary care offices from 44 US states, Puerto Rico, and Canada. PATIENTS: From 21 150 children seen in office visits, we selected children with an identified psychosocial problem but who were not already receiving specialty mental health services (n = 2618 children). OUTCOME MEASURES: Clinicians' decisions to counsel families, to refer children to mental health specialists, or to prescribe medication. RESULTS: The treatment choices of primary care clinicians (PCCs) were generally independent of patients' demographics or insurance status. Clinicians' training, beliefs about mental health, and practice structure had no effect on treatment choices. However, clinicians seeing their own patients were more likely to prescribe medications for attention problems. The clinician's perception about whether the parent agreed with the treatment choice was important for every treatment modality. Counseling and referral were more common and medication was less common when a problem was newly recognized at the visit. CONCLUSIONS: Structural factors such as practice type, insurance coverage, and physician training were less important for treatment than were process factors, such as whether the visit was a psychosocial problem visit, whether the problem was newly or previously recognized, and whether the family and clinician were familiar with each other and in accord about treatment.

Analytical methodology for assays of serum tryptophan metabolites in control subjects and newly abstinent alcoholics: preliminary investigation by liquid chromatography with amperometric detection.

A rapid, isocratic assay for the determination of all major tryptophan metabolites in serum samples from control non-alcoholic subjects, recovered alcoholics and newly abstinent alcoholics is described. The sample preparation involves only precipitation of protein with sulfosalicylic acid. The complete liquid chromatographic analysis is short (25 min) and the sensitivity of amperometric detection permits the routine assessment of catabolites at the picogram level. This preliminary longitudinal study of the basal and post-tryptophan load serum metabolites revealed a considerable scatter of experimental results for kynurenine and serotonin in all groups examined, probably owing to the clinical heterogeneity of the sample populations.

The case for a services-based approach to payment for mental illness under national health care reform.

In this position paper drafted by the committee on psychopathology of the Group for the Advancement of Psychiatry, the authors discuss merits and disadvantages of three different approaches to equitable coverage of mental illness: coverage for selected psychiatric diagnoses, coverage based on severity of impairment, and coverage of services. They believe that coverage of selected disorders has political appeal but is discriminatory and arbitrary; it is also impractical because clinicians may overdiagnose conditions covered by insurance and underdiagnose excluded conditions. Coverage based on severity of impairment, or disability, has similar limitations. The authors believe services should be the principal basis for coverage, as under general medical insurance. The approach is nondiscriminatory, and costs can be controlled through such means as managed care, changes in the payment system, or benefit design.