The Role of Behavioral Phenotypes on Impaired Driving Recidivism Risk and Treatment Response to Brief Intervention: A Preliminary Study.

BACKGROUND: Heterogeneity in the driving while impaired (DWI) offender population and modest outcomes from remedial programs are fueling interest in clarifying clinically significant DWI subtypes to better assess recidivism risk and target interventions. Our previous research identified 2 putative behavior phenotypes of DWI offenders with distinct behavioral, personality, cognitive, and neurobiological profiles: (i) offenders primarily engaging in DWI (pDWI); and (ii) offenders engaging in DWI and other traffic violations (MIXED). Here, we evaluate these phenotypes' clinical significance for prediction of recidivism and intervention targeting. METHODS: DWI recidivists participating in a previous randomized controlled trial (N = 184 comparing brief motivational interviewing (BMI) and an information and advice control condition (IA) were retrospectively classified as either pDWI (n = 97) or MIXED (n = 87). Secondary analyses then evaluated the effect of this phenotypic classification on self-reported 6- and 12-month alcohol misuse outcomes and documented 5-year DWI recidivism violations, and in response to either BMI or IA (i.e., pDWI-BMI, n = 46; MIXED-BMI, n = 45; pDWI-IA, n = 51; MIXED-IA, n = 42). Two hypotheses were tested: (i) MIXED classification is associated with poorer alcohol misuse outcomes and recidivism outcomes than pDWI classification; and (ii) pDWI paired with BMI is associated with better outcomes compared to MIXED paired with BMI. RESULTS: MIXED classification was associated with significantly greater risk of recidivism over the 5-year follow-up compared to pDWI classification. Moreover, the pDWI-BMI pairing was associated with significantly decreased recidivism risk compared to the MIXED-BMI pairing. Analyses of 6- and 12-month alcohol use outcomes produced null findings. CONCLUSIONS: The clinical significance of phenotypic classification for risk assessment and targeting intervention was partially supported with respect to recidivism risk. Prospective investigation of this and other behavioral phenotypes is indicated.

[The changes in values and beliefs through the first 50 years of the department of Psychiatry at the University of Montreal]. / Le changement de nos valeurs et certitudes au long de ce demi-siècle.

This essay attempts to describe and discuss the major changes in values and fundamental beliefs related to clinical practice within the Département de psychiatrie de l'Université de Montréal since its creation fifty years ago.Being an essay, the methods include shared recollections, discussions with colleagues, especially between the co-authors, and the study of some documents related to the practice of psychiatry 40 to 50 years ago.Five major axes of change are proposed: 1- From psychoanalysis to brain diseases, 2- From "Can a non-physician practice psychoanalysis?" to "Can a psychiatrist still perform psychotherapy?" 3- From continuity of care to episodes of treatment, 4- From treatment first to repeated assessments of patients, 5- From love that can heal and repair to a taboo of love.Finally it is suggested that the increasing emphasis on psychopharmacology and on DSM classifications has contributed to a shift from attempts to understand the intimate nature of symptoms and suffering to a priority given to rather mechanical clinical assessments in search of "objective" criteria.

A randomized controlled trial of brief motivational interviewing in impaired driving recidivists: a 5-year follow-up of traffic offenses and crashes.

BACKGROUND: In a previously published randomized controlled trial (Brown et al. Alcohol Clin Exp Res 2010; 34, 292-301), our research team showed that a 30-minute brief motivational interviewing (BMI) session was more effective in reducing percentages of risky drinking days in drunk driving recidivists than a control information-advice intervention at 12-month follow-up. In this sequel to the initial study, 2 main hypotheses were tested: (i) exposure to BMI increases the time to further arrests and crashes compared with exposure to the control intervention (CTL) and (ii) characteristics, such as age, moderate the benefit of BMI. METHODS: A sample of 180 community-recruited recidivists who had drinking problems participated in the study. Participants gave access to their provincial driving records at baseline and were followed up for a mean of 1,684.5 days (SD = 155.7) after randomization to a 30-minute BMI or CTL session. Measured outcomes were driving arrests followed by convictions including driving while impaired (DWI), speeding, or other moving violations as well as crashes. Age, readiness to change alcohol consumption, alcohol misuse severity, and number of previous DWI convictions were included as potential moderators of the effect of the interventions. RESULTS: For arrests, Cox proportional hazards modeling revealed no significant differences between the BMI and the CTL group. When analyses were adjusted to age tertile categories, a significant effect of BMI in the youngest age tertile (<43 years old) emerged. For crashes, no between-group differences were detected. CONCLUSIONS: BMI was better at delaying DWI and other dangerous traffic violations in at-risk younger drivers compared with a CTL similar to that provided in many remedial programs. BMI may be useful as an opportunistic intervention for DWI recidivism prevention in settings such as DWI courts. Treatment effectiveness studies are needed to ascertain how the present findings generalize to the real-world conditions of mandated relicensing programs.

Brief motivational interviewing for DWI recidivists who abuse alcohol and are not participating in DWI intervention: a randomized controlled trial.

BACKGROUND: Driving while impaired (DWI) recidivists with unresolved alcohol use problems pose an ongoing risk for traffic safety. Following conviction, many do not participate in mandated alcohol evaluation and intervention programs, or continue to drink problematically after being relicensed. This study investigated if, in DWI recidivists with alcohol problems and not currently involved in DWI intervention, Brief Motivational Interviewing (BMI) produced greater reductions in risky drinking at 6- and 12-month follow-up compared to an information-advice control condition. Additional analyses explored whether BMI was associated with greater readiness to change, subsequent substance abuse treatment service utilization, and satisfaction compared to the control condition. METHODS: Male and female recidivists with drinking problems and not currently engaged in DWI intervention were recruited, evaluated, and then randomly assigned to receive 1 of 2 manualized interventions: 30-minute BMI session or information-advice. Participants, interviewers, researchers, and statisticians were blind to assignment. Outcomes were changed in: percent of risky drinking days (i.e., > or =3 standard drinks/d for males; > or =2 for females) in the previous 6 months derived from the Timeline Followback, biomarkers of alcohol abuse (GGT, AST, ALT, MCV) by blood assay, and alcohol abuse-related behaviors using the MMPI-Mac scale. Data from the Readiness to Change Questionnaire, a substance abuse service utilization questionnaire, and the Client Satisfaction Scale were also collected. RESULTS: Analyses revealed significant declines in risky drinking with both interventions. BMI (n = 92) resulted in a 25% reduction in risky drinking days at 12-month follow-up, which compared to the control intervention (n = 92) represented a significant decline from 6-month levels. Exposure to BMI also produced significantly greater improvement at 6-month follow-up in a biomarker of alcohol abuse and a behavioral measure related to recidivism risk. Exploration of readiness to change, substance abuse service utilization, and satisfaction with intervention indicated a perception of BMI being more useful in coping with problems. CONCLUSIONS: Brief MI approaches warrant further implementation and effectiveness research as an opportunistic DWI intervention strategy to reduce risks associated with alcohol use outside of clinical and DWI relicensing settings.

Genetical genomic determinants of alcohol consumption in rats and humans.

BACKGROUND: We have used a genetical genomic approach, in conjunction with phenotypic analysis of alcohol consumption, to identify candidate genes that predispose to varying levels of alcohol intake by HXB/BXH recombinant inbred rat strains. In addition, in two populations of humans, we assessed genetic polymorphisms associated with alcohol consumption using a custom genotyping array for 1,350 single nucleotide polymorphisms (SNPs). Our goal was to ascertain whether our approach, which relies on statistical and informatics techniques, and non-human animal models of alcohol drinking behavior, could inform interpretation of genetic association studies with human populations. RESULTS: In the HXB/BXH recombinant inbred (RI) rats, correlation analysis of brain gene expression levels with alcohol consumption in a two-bottle choice paradigm, and filtering based on behavioral and gene expression quantitative trait locus (QTL) analyses, generated a list of candidate genes. A literature-based, functional analysis of the interactions of the products of these candidate genes defined pathways linked to presynaptic GABA release, activation of dopamine neurons, and postsynaptic GABA receptor trafficking, in brain regions including the hypothalamus, ventral tegmentum and amygdala. The analysis also implicated energy metabolism and caloric intake control as potential influences on alcohol consumption by the recombinant inbred rats. In the human populations, polymorphisms in genes associated with GABA synthesis and GABA receptors, as well as genes related to dopaminergic transmission, were associated with alcohol consumption. CONCLUSION: Our results emphasize the importance of the signaling pathways identified using the non-human animal models, rather than single gene products, in identifying factors responsible for complex traits such as alcohol consumption. The results suggest cross-species similarities in pathways that influence predisposition to consume alcohol by rats and humans. The importance of a well-defined phenotype is also illustrated. Our results also suggest that different genetic factors predispose alcohol dependence versus the phenotype of alcohol consumption.

A sex-specific role of type VII adenylyl cyclase in depression.

Major depression represents a complex mental disorder. The identification of biological markers that define subtypes of major depressive disorder would greatly facilitate appropriate medical treatments, as well as provide insight into etiology. Reduced activity of the cAMP signaling system has been implicated in the etiology of major depression. Previous work has shown low adenylyl cyclase activity in platelets and postmortem brain tissue of depressed individuals. Here, we investigate the role of the brain type VII isoform of adenylyl cyclase (AC7) in the manifestation of depressive symptoms in genetically modified animals, using a combination of in vivo behavioral experiments, gene expression profiling, and bioinformatics. We also completed studies with humans on the association of polymorphisms in the AC7 gene with major depressive illness (unipolar depression) based on Diagnostic and Statistical Manual of Mental Disorders IV criteria. Collectively, our results demonstrate a sex-specific influence of the AC7 gene on a heritable form of depressive illness.

Neurocognitive characteristics of DUI recidivists.

Individuals who drive under the influence (DUI) of alcohol may be at greater risk for neurocognitive impairment because of their exposure to multiple sources of neurological risk. This could contribute to the persistence of DUI behaviour and influence the effectiveness of remedial interventions. The objectives of this study were to clarify the neurocognitive characteristics of DUI recidivists and the nature of potential impairments, and to explore relationships between these characteristics and the frequency of past DUI convictions. One hundred male recidivists were evaluated for visuospatial constructional abilities and visual memory, verbal fluency, attention skills, cognitive flexibility, spatial planning, and verbal and movement inhibition. Results indicated that a majority of recidivists showed signs of neurocognitive impairment on several dimensions. Impairment was most marked on visuospatial constructional abilities and visual memory. In contrast to previous studies, no participants were found to have impulse control problems. Measures of memory and cognitive efficiency were significantly associated with the frequency of past convictions. Finally, exploratory analyses of two potential sources of impairment, alcohol exposure and head trauma, suggested the role of excessive alcohol use as the most obvious associated factor. Overall, the findings indicate that neurocognitive impairments are a common feature in recidivists and may contribute to DUI persistence. Development of a DUI-specific neurocognitive assessment and greater understanding of how neurocognitive status influences DUI risk could lead to remediation strategies better adapted to the individual characteristics of recidivists.

The role of demographic characteristics and readiness to change in 12-month outcome from two distinct brief interventions for impaired drivers.

OBJECTIVES: This study tested specific intervention responsivity to brief intervention in driving while impaired by alcohol and/or drugs recidivists based upon their demographic, substance use, and initial readiness to change characteristics. METHODS: A nonclinical community-based sample of 184 male and female recidivists was randomly assigned to receive one of two 30-minute interventions: brief motivational interviewing (n = 92) or an information-advice session (n = 92). Dependent variables were change at the 6- and 12-month follow-ups from baseline in percentage of risky drinking days and blood assay biomarkers of alcohol misuse. Independent variables were age, gender, education, past convictions for impaired driving, and baseline alcohol and drug misuse severity and readiness to change. RESULTS: Recidivists who were younger, male, and exhibited more negative consequences and ambivalence towards their problem drinking improved more on alcohol-related outcomes, irrespective of intervention type. CONCLUSIONS: The results do not convincingly indicate specific intervention responsivity based upon participant characteristics but provide preliminary guidance about which recidivists are most apt to benefit from these brief approaches.

From the brain to bad behaviour and back again: neurocognitive and psychobiological mechanisms of driving while impaired by alcohol.

ISSUES: Driving while impaired by alcohol (DWI) is responsible for substantial mortality and injury. Significant gaps in our understanding of DWI re-offending, or recidivism, reduce our ability to practically assess recidivism probability and to match interventions to individual risk profiles. These shortcomings reflect the baffling heterogeneity in the DWI population and the limited focus of much existing DWI recidivism research to psychosocial, psychological and substance use correlates. APPROACH: This narrative review summarises the evidence for the contribution of neurocognitive and psychobiological mechanisms to DWI behaviour and recidivism. Given the nascent nature of this literature, insight into the putative contribution of these mechanisms to DWI is also drawn from other experimental literatures, particularly those on alcohol use disorders and cognitive and behavioural neuroscience. KEY FINDINGS: Alcohol-related neurotoxicity and dysregulation of hypothalamic-pituitary-adrenal axis and serotonergic systems may underlie certain offender characteristics consistently correlated with heightened DWI risk, persistence and intervention resistance. Their markers are less vulnerable to sources of bias than subjective psychosocial indices and are more far-reaching than alcohol abuse in explaining DWI behaviour and recidivism. Implications. The investigation of neurocognitive and psychobiological mechanisms in DWI research is a promising avenue for discerning clinically meaningful subgroups within the DWI population. This can lead to research and development in alternative assessment and more targeted intervention technologies. CONCLUSION: Multidimensional research in DWI and recidivism offers novel avenues for increasing road safety.

DUI offenders who delay relicensing: a quantitative and qualitative investigation.

OBJECTIVES: As in many jurisdictions, individuals convicted of driving under the influence (DUI) in the province of Quebec are mandated to relicensing programs, which include obligatory participation in intervention programs. However, prolonged delay in relicensing is widespread, potentially contributing to unlicensed driving, untreated substance misuse problems, and drink-driving risk. Information about the characteristics of DUI offenders who delay relicensing (DR) is sparse. This investigation compares the characteristics of DR offenders with those offenders who do not delay (NoDR). In addition, the rationales of DR offenders for delaying relicensing are explored qualitatively. METHODS: Two studies were conducted to explore the characteristics of DR offenders. In Study 1, DR offenders (n = 46) were compared to NoDR offenders (n = 74) on multidimensional measures of psychosocial functioning, driving behavior, substance use, and psychological and neurocognitive characteristics. In Study 2, a qualitative examination of 20 DR offenders' reasons underlying delayed relicensing was undertaken, with verbatims content analyzed to identify major themes. A questionnaire, based upon this preliminary analysis, was then administered to another sample of DR participants (N = 37) to appraise and confirm thematic comprehensiveness. RESULTS: The main findings of Study 1 were that, compared to NoDR offenders, DR offenders had more past DUI convictions, were at greater risk for drink driving per kilometer (km) driven, were more likely to have received substance abuse treatment, and exhibited indices of poorer neurocognitive performance in visual memory and behavioral inhibition domains. No group differences were uncovered on substance use measures. The findings of Study 2 revealed that the expense of participation, availability of alternate transportation, lack of interest, and no access to a vehicle were the most frequent explanations for delayed relicensing. CONCLUSIONS: Overall, these findings suggest that both individual and contextual factors influence timely fulfillment of relicensing requirements. While the cost of relicensing may succeed in removing some offenders from the road, it may also be a barrier for others at risk for drink driving, preventing exposure to needed intervention programs. Reducing this barrier may need to be weighted against the risks of relicensing more DUI offenders. Neurocognitive factors may need to be taken into account to not only decrease delay in relicensing but also increase the benefits from participation in interventions that are part of current relicensing programs.

Motivational interviewing and clinical psychiatry.

OBJECTIVES: Our objectives were as follows: (1) to survey the literature on motivational interviewing (MI), "a client-centered yet directive method for enhancing intrinsic motivation to change by exploring and resolving client ambivalence" and a well-established method of brief intervention, especially in the field of addictions treatment; (2) to review hypotheses about its mode of action; and (3) to discuss its possible impact on clinical psychiatry, in particular, on teaching communications skills. METHOD: Literature reviews and metaanalyses of numerous clinical trials of MI for addictions treatment have already been published and are briefly summarized. So far, no literature survey exists for MI applied to psychiatric patients. This review is limited to a synthesis of the articles relevant to psychiatry and to comments based on our team's experiences with MI. RESULTS: There is no evidence that MI achieves better results than other established techniques for treating addictions; it may simply work faster. The explanation for the method's rapid effectiveness remains speculative. Outcomes concerning the application of MI to psychiatric patients, although preliminary, are promising. Methods of assessing the integrity of MI treatment are more developed than in most psychotherapies, which permits the learning progress of trainees to be measured. CONCLUSIONS: MI offers a complement to usual psychiatric procedures. It may be worthwhile to teach it, not only for addictions but also for other broad treatment issues, such as enhancing patients' medication compliance and professionals' communication skills. Questions remain concerning MI's feasibility in psychiatry settings.

Salivary cortisol: a predictor of convictions for driving under the influence of alcohol?

AIMS: To examine the relationship between salivary cortisol and frequency of past driving under the influence of alcohol (DUI) convictions. METHODS: A total of 104 males with previous DUI convictions (from one to eight) and mean age of 44.7 years were assessed on measures characterizing repeat DUI offenders, including sociodemographic information, alcohol use behaviours, biological indices of the organic consequences of chronic abuse, negative consequences of excessive drinking, past DUI conviction history, impulse control, and antisocial behaviour tendencies. Saliva samples were taken approximately every 30 min over a 6 h period during an exhaustive multidimensional assessment protocol, and were then assayed to obtain cortisol responses. RESULTS: Blunted cortisol response, typically observed in alcoholics and in high-risk non-alcoholics, was associated with increased number of past DUI convictions. This association was particularly pronounced in multiple DUI offenders, and was stronger than, and independent of, other measures of alcohol use severity and chronicity commonly used for DUI assessment. CONCLUSIONS: Cortisol response may be useful in understanding the mediators underlying repeat DUI offending and the frequent failure of intervention efforts in curbing DUI behaviour.

Evidence in an international sample of alcohol-dependent subjects of subgroups with specific symptom patterns of antisocial personality disorder.

BACKGROUND: An earlier latent class analysis (LCA) of the symptoms of antisocial personality disorder in alcohol-dependent subjects enrolled in the Montreal sample of the WHO/ISBRA Study on State and Trait Markers of Alcohol Use and Dependence suggested a three-class qualitative solution. The present analysis of a larger, international WHO/ISBRA sample provides evidence of a four-class solution with expanded symptomatic differentiation. METHODS: An unrestricted LCA of 15 antisocial behaviors expressed after 15 years of age was performed in 465 males with DSM-IV diagnosis of alcohol dependence, from the Montreal center (n = 120, overlapping the previous LCA), Helsinki (n = 80), São Paolo (n = 145), Sapporo (n = 22), and Sydney (n = 98); subjects were of various races, were ascertained from various sources, and showed a wide range of social adjustment. RESULTS: Four latent classes that appeared to differ qualitatively were identified. For descriptive purposes, the classes are termed socially adjusted adults (SAA, n = 197), antisocial work-adjusted adults (AWAA, n = 126), antisocial work-maladjusted adults (AWMA, n = 120), and antisocial aggressive adults (AAA, n = 23). The AAA class had the earliest age of onset for alcohol dependence, which decreased across classes. Proportion of alcohol-dependent first-degree relatives was low in the SAA class (13.6%), moderate in the AWAA and the AWMA classes (20.8% and 18.7% respectively), and high in the AAA class (33.3%). CONCLUSIONS: It is unknown if and to what extent racial, cultural, and ascertainment heterogeneity between collaborating centers might have influenced these analyses. The results presented here show qualitative differences among antisocial alcohol-dependent individuals in job adjustment and aggressive behavior, but only the latter distinction was relevant to familial alcohol dependence. Moreover, both the aggressive class and socially adjusted class differed in familial loading for alcohol dependence from the remaining two antisocial classes. These data provide improved empirical support for qualitative differentiation of aggressive from nonaggressive antisocial alcohol-dependent individuals and might also have nosological implications for antisocial personality disorder.