Nighttime Sleep Quality and Daytime Sleepiness Predicts Suicide Risk in Adults Admitted to an Inpatient Psychiatric Hospital.

As sleep problems have been identified as an important, yet understudied, predictor of suicide risk, the present study analyzed the relationship between daytime sleepiness and nighttime sleep disturbance in a high-risk population of adults admitted to an inpatient psychiatric hospital. Objectives were to (1) examine the time course of subjective daytime sleepiness, nighttime sleep disturbance, and suicide risk throughout inpatient psychiatric treatment, (2) examine pre- to post-treatment changes in sleep disturbance with treatment as usual in an inpatient psychiatric setting, and (3) investigate whether daytime sleepiness and nighttime sleep disturbance predicted suicide risk above and beyond anxiety and depression. Participants were 500 consecutively admitted adults admitted to an intermediate length of stay (4-6 weeks) inpatient psychiatric hospital (47% female; 18-87 years of age). Measures of sleep, suicide risk, depression, and anxiety were completed at admission, weeks 1 through 4, and at discharge. Latent growth curve modeling (LGM) and hierarchal linear modeling (HLM) were conducted. The LGM analysis demonstrated that daytime sleepiness, nighttime sleep disturbance, and suicide risk all improved throughout inpatient treatment. Further, HLM showed that daytime sleepiness predicted suicide risk above and beyond symptoms of anxiety, depression, major sleep medications, and prior suicidal ideation and attempts, while nighttime sleep disturbance predicted suicide risk above and beyond symptoms of anxiety, major sleep medications, and prior suicidal ideation and attempts. Findings indicate the need to reevaluate safety protocols that may impact sleep, particularly that may increase daytime sleepiness, and to develop evidence-based sleep interventions for individuals admitted to inpatient psychiatric hospitals.

Nature and Assessment of Personality Pathology and Diagnosis.

This article demonstrates the contribution of Otto Kernberg's object relations theory of personality pathology to the current understanding of the nature and assessment of personality pathology and diagnosis. The article introduces recent advances in psychiatric nosology and presents differing views on the meaning of the general severity criterion common to all personality pathology (i.e., level of personality functioning as described in criterion A of the Alternative DSM-5 Model for Personality Disorders). Next, the significance of Kernberg's theory to recent nosological advances is discussed, with a focus on two important features: first, a definition of personality that goes beyond signs and symptoms to include structural motivational components, in the domains of self- and interpersonal functioning, that are common to all personality manifestations and that fulfill an intrapsychic, organizing function; second, identity formation and consolidation as the ultimate end point of healthy personality functioning. That these cornerstone features of Kernberg's theory, articulated more than 50 years ago, align with the most up-to-date conceptualization of personality pathology confirms that Kernberg's theory represents an idea whose time has finally come.

Predicting depression outcomes throughout inpatient treatment using the general and specific personality disorder factors.

BACKGROUND: Clinical intuition suggests that personality disorders hinder the treatment of depression, but research findings are mixed. One reason for this might be the way in which current assessment measures conflate general aspects of personality disorders, such as overall severity, with specific aspects, such as stylistic tendencies. The goal of this study was to clarify the unique contributions of the general and specific aspects of personality disorders to depression outcomes. METHODS: Patients admitted to the Menninger Clinic, Houston, between 2012 and 2015 (N = 2352) were followed over a 6-8-week course of multimodal inpatient treatment. Personality disorder symptoms were assessed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th edition Axis II Personality Screening Questionnaire at admission, and depression severity was assessed using the Patient Health Questionnaire-9 every fortnight. General and specific personality disorder factors estimated with a confirmatory bifactor model were used to predict latent growth curves of depression scores in a structural equation model. RESULTS: The general factor predicted higher initial depression scores but not different rates of change. By contrast, the specific borderline factor predicted slower rates of decline in depression scores, while the specific antisocial factor predicted a U shaped pattern of change. CONCLUSIONS: Personality disorder symptoms are best represented by a general factor that reflects overall personality disorder severity, and specific factors that reflect unique personality styles. The general factor predicts overall depression severity while specific factors predict poorer prognosis which may be masked in prior studies that do not separate the two.

Association of TPH1 and serotonin transporter genotypes with treatment response for suicidal ideation: a preliminary study.

Variants in three genes coding for components of the serotonergic system, the tryptophan hydroxylase 1 (TPH1) rs1799913, serotonin transporter (SLC6A4) 5-HTTLPR, and serotonin receptor 2A (HTR2A) rs6311, were evaluated for association with suicidal ideation (SI) and with recovery from SI in a psychiatric inpatient population. Five hundred and eighty-two adult inpatients, including 390 patients who had SI, collected from December 2012 to April 2016 were assessed. SI recovery, calculated as change in SI between the first two-week period after admission and weeks 5 and 6, was appraised for association with the three variants. In this preliminary study, both TPH1 and 5-HTTLPR genotypes were associated with recovery (TPH1: recessive model, increased recovery with AC genotype, P = 0.026; additive model, increased recovery with AC genotype, P = 0.037; 5-HTTLPR: recessive model, increased recovery with AC, P = 0.043). When patients with comorbid alcohol use disorder (AUD) were removed, given that TPH1 has been associated with alcoholism, the associations of those recovered from SI with TPH1 rs1799913 remained significant for the additive (increased recovery with AC, P = 0.045) and recessive (increased recovery with C-carriers, P = 0.008) models, and with 5-HTTLPR using the dominant model (increased recovery with S'S', P = 0.016). In females, an association of SI recovery with TPH1 rs1799913 was found using a recessive model (increased recovery with C-carriers, P = 0.031), with 5-HTTLPR using additive (increased recovery with L'S', P = 0.048) and recessive (increased recovery with S'S', P = 0.042) models. Additionally, an association of SI with TPH1 rs1799913 was found in females using both additive (increased risk in AC, P = 0.033) and recessive (increased risk in C-carriers, P = 0.043) models, and with 5-HTTLPR using a recessive model (increased risk in S'S', P = 0.030). This study provides evidence that variation in the TPH1 and serotonin transporter genes play key roles in moderating recovery from SI during treatment in an inpatient psychiatric clinic.

Clinical utility of the DSM-5 alternative model for borderline personality disorder: Differential diagnostic accuracy of the BFI, SCID-II-PQ, and PID-5.

BACKGROUND: With the publication of DSM 5 alternative model for personality disorders it is critical to assess the components of the model against evidence-based models such as the five factor model and the DSM-IV-TR categorical model. This study explored the relative clinical utility of these models in screening for borderline personality disorder (BPD). METHODS: Receiver operator characteristics and diagnostic efficiency statistics were calculated for three personality measures to ascertain the relative diagnostic efficiency of each measure. A total of 1653 adult inpatients at a specialist psychiatric hospital completed SCID-II interviews. Sample 1 (n=653) completed the SCID-II interviews, SCID-II Questionnaire (SCID-II-PQ) and the Big Five Inventory (BFI), while Sample 2 (n=1,000) completed the SCID-II interviews, Personality Inventory for DSM5 (PID-5) and the BFI. RESULTS: BFI measure evidenced moderate accuracy for two composites: High Neuroticism+ low agreeableness composite (AUC=0.72, SE=0.01, p<0.001) and High Neuroticism+ Low+Low Conscientiousness (AUC=0.73, SE=0.01, p<0.0001). The SCID-II-PQ evidenced moderate-to-excellent accuracy (AUC=0.86, SE=0.02, p<0.0001) with a good balance of specificity (SP=0.80) and sensitivity (SN=0.78). The PID-5 BPD algorithm (consisting of elevated emotional lability, anxiousness, separation insecurity, hostility, depressivity, impulsivity, and risk taking) evidenced moderate-to-excellent accuracy (AUC=0.87, SE=0.01, p<0.0001) with a good balance of specificity (SP=0.76) and sensitivity (SN=0.81). CONCLUSIONS: Findings generally support the use of SCID-II-PQ and PID-5 BPD algorithm for screening purposes. Furthermore, findings support the accuracy of the DSM 5 alternative model Criteria B trait constellation for diagnosing BPD. Limitations of the study include the single inpatient setting and use of two discrete samples to assess PID-5 and SCID-II-PQ.

A Novel Approach to Identifying a Neuroimaging Biomarker for Patients With Serious Mental Illness.

Serious mental illness (SMI) is disabling, and current interventions are ineffective for many. This exploratory study sought to demonstrate the feasibility of applying topological data analysis (TDA) to resting-state functional connectivity data obtained from a heterogeneous sample of 235 adult inpatients to identify a biomarker of treatment response. TDA identified two groups based on connectivity between the prefrontal cortex and striatal regions: patients admitted with greater functional connectivity between these regions evidenced less improvement from admission to discharge than patients with lesser connectivity between them. TDA identified a potential biomarker of an attenuated treatment response among inpatients with SMI. Insofar as the observed pattern of resting-state functional connectivity collected early during treatment is replicable, this potential biomarker may indicate the need to modify standard of care for a small, albeit meaningful, percentage of patients.

A Systematic Analysis of Treatment Effects on Depressive Symptom Severity by Level of Coercion.

Few studies examine the effect of interpersonal, regulatory or legal coercion on the treatment of depressive symptoms. This retrospective case-control study compared the recovery rates of 574 adults whose level of coercion was scored on a 0-3 scale from fully voluntary to severe coercion when admitted to the Menninger Clinic between 2009 and 2014. The change in Patient Health Questionnaire-9 (PHQ-9) scores (measuring depression severity) from admission to discharge served as the primary outcome measure. Level of coercion was not associated with a difference in rate of improvement in PHQ-9 score. Greater improvement in PHQ-9 scores was associated with (a) older age, (b) lack of a psychotic spectrum disorder diagnosis, (c) stronger working alliance with treatment team, and (d) less difficulty with emotional regulation [lower Difficulties in Emotion Regulation Scale (DERS) scores]. DERS scores were the most impactful factor. This study suggests that licensure boards can continue to mandate treatment despite concerns that coercion may decrease treatment effectiveness.

Improvements in Somatic Complaints Among Individuals With Serious Mental Illness Receiving Treatment in a Psychiatric Hospital.

OBJECTIVE: Individuals with serious mental illness (SMI) experience significant comorbid somatic complaints. Little is known about response to integrated inpatient care that addresses psychiatric and general medical needs among individuals with SMI. METHODS: Latent growth curve analyses were used to model somatic symptom trajectories across adult inpatients with SMI (n = 989). The Patient Health Questionnaire-15 (PHQ-15) was administered at admission, every 14 days, and at discharge. RESULTS: Patients evidenced substantial reduction in somatization from admission (mean [standard deviation] = 9.0 [5.2]) to discharge (mean [standard deviation] = 5.2 [4.4]), with large effects (d = 0.83, 95% confidence interval = 0.76-0.90). Results indicate nonlinear improvement in somatic symptoms for 8 weeks of treatment, with greatest symptom reduction occurring during the first weeks of treatment with continued, albeit slowed, improvement until discharge. Initial PHQ-15 scores were lower among men and those who reported regular exercise in the 30 days preceding this hospitalization. In addition, presence of an anxiety disorder or personality disorder at admission; history of trauma, a gastrointestinal disorder, or major medical illness (within the past 3 months); and significant sleep disturbance independently contribute to higher PHQ-15 scores at admission. A substance use disorder and sleep disturbance were associated with greater immediate symptom reduction. CONCLUSIONS: Somatic complaints can be managed in the context of inpatient psychiatric care integrated with 24-hour nursing and internal medicine specialists. Addressing psychiatric impairments, improving sleep, and ensuring abstinence from drugs and alcohol are associated with significant improvement in somatic complaints.

Capitated budgets are a good deal for long term conditions.

A bold programme demonstrated they were needed in the mainstream - and attracted global interest.

A dimensional approach to assessing personality functioning: examining personality trait domains utilizing DSM-IV personality disorder criteria.

BACKGROUND: This study compared a dimensional, trait domain approach to characterizing personality pathology with the traditional polythetic approach with respect to their associations with interpersonal functioning and personality traits from the five factor model. METHODS: Psychiatric inpatients (N=1476) were administered the Structured Clinical Interview for DSM-IV Axis II personality disorders. Dimensional representations of trait domains were derived from reorganizing DSM-IV criteria into personality trait domains from DSM-5 Alternative Model. Dimensional scores and personality disorder (PD) total criterion scores served as independent variables in predicting interpersonal profile clusters, as well as extraversion, agreeableness conscientiousness, neuroticism and openness from the five factor model traits. RESULTS: Trait domain scores and PD criteria totals were significantly correlated with submissive interpersonal style yet none proved significant in regression analyses. Avoidant and borderline PD total criteria were negatively associated with a normative interpersonal style. Combined trait domain of detachment and avoidant PD total criteria predicted a hostile/withdrawn interpersonal style. The trait domain of detachment was negatively associated with five factor traits of extroversion, whereas borderline PD total criteria were negatively associated with conscientiousness. Avoidant and borderline PD total criteria were positively associated with neuroticism. CONCLUSIONS: The cross-cutting dimensional approach provided useful information in predicting a hostile/withdrawn interpersonal style as well as extroversion. Importantly, PD criterion scores and dimensional trait scores combined to predict this interpersonal style providing support to the alternative model of personality diagnosis in DSM-5. Clinicians are encouraged to assess dimensions of personality traits as these are related to interpersonal problems frequently encountered in psychiatric settings. While potentially useful, the dimensional approach articulated here did not yield substantial prediction of behavior.

Changes in the Beck Depression Inventory-II's underlying symptom structure over 1 month of inpatient treatment.

Research has not investigated changes in the symptom structure of depression over the course of mental health treatment. In the present study, 1025 psychiatric inpatients were recruited and assessed for depression symptom severity using the Beck Depression Inventory-II (BDI-II) at admission and after 1 month of treatment. A three-factor BDI-II model was tested using confirmatory factor analysis and fit reasonably well at both time points. Measurement invariance testing results demonstrated that factor loadings increased, indicating that the meaning of the three underlying depression dimensions changed through treatment. However, observed variable intercepts and residual error variances decreased significantly after 1 month of treatment, reflecting decreases in symptom severity as well as measurement error. Thus, depressive symptom severity decreased over the course of treatment, and the underlying factor structure of depression improved in fit after treatment. Implications for changes to the structure of depression symptoms and in the clinical practice of tracking depression over time are discussed.

Reward Processing in Psychiatric Inpatients With Depression.

BACKGROUND: Previous neuroimaging studies have investigated reward-processing dysfunction in major depressive disorder and have led to the common finding that major depressive disorder is associated with reduced reward responses within the reward circuit. Yet it is unclear whether such reward-processing dysfunction is specifically associated with the severity of depressive symptoms in major depressive disorder or is associated with common comorbidities. METHODS: We investigated reward-processing differences using a classic juice-delivery functional magnetic resonance imaging experiment to compare psychiatric patients with severe depressive symptoms (DEPs) to both psychiatric control subjects (PCs) and healthy control subjects. In this study, the DEPs (n = 108) were matched to healthy control subjects (n = 62) for demographic characteristics and to the PCs (n = 108) for demographics and comorbid psychiatric diagnoses. An a priori region of interest, the left putamen, was selected using previous studies. An exploratory whole-brain analysis was performed to explore for nonhypothesized regions. RESULTS: Relative to the PCs and healthy control subjects, the DEP group showed smaller responses to reward stimulus in the left putamen. Whole-brain exploratory analysis revealed that DEPs had significantly lower responses to reward stimulus in the bilateral dorsal striatum (putamen and caudate), middle frontal gyrus, left precentral gyrus, and middle cingulate cortex than PCs. CONCLUSIONS: Our findings suggest that DEPs may have a lesser ability to modulate behavior as a function of reward, especially in those individuals who experience the most severe depressive symptoms. In both DEPs and PCs, the severity of depressive symptoms was related to reduced reward responses in the left putamen.

Impact of personality dysfunction on interdisciplinary treatment team working alliance in an inpatient psychiatric population.

Cluster B personality disorders (PDs) share specific traits that can result in interpersonal conflict. As therapeutic working alliance has a strong relationship with improved outcomes, there is interest in understanding the relationship between PDs, working alliance, and clinical outcomes. This is especially compelling in inpatient populations, where symptoms are severe, and patients are working with a treatment team. The aims of this study were to (a) assess whether higher team working alliance is associated with lower depressive symptoms, (b) assess whether patients with Cluster B PD traits have worse working alliance with their team than patients without those Cluster B PD traits, and (c) assess whether higher team working alliance is associated with lower depressive symptoms when Cluster B PD traits are present. Team working alliance was measured at baseline and at discharge for 3,406 inpatients at a psychiatric hospital. Improved team working alliance was associated with lower depression scores at discharge. Patients with borderline personality disorder traits had worse team working alliance, whereas patients with narcissistic personality disorder and antisocial personality disorder traits had similar working alliance scores as other patients. Borderline personality disorder and antisocial personality disorder traits moderated the association between team working alliance and depressive symptoms differently. Findings suggest that team working alliance works similarly to therapist working alliance. Of clinical importance is the finding that team working alliance and its relationship with depression symptoms differ based on Cluster B PD traits, and the importance of strong working alliance regardless of interpersonal challenges due to personality pathology. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

miR-124-3p target genes identify globus pallidus role in suicide ideation recovery in borderline personality disorder.

Borderline personality disorder (BPD) is characterized by patterns of unstable affect, unstable interpersonal relationships, and chronic suicidal tendencies. Research on the genetics, epigenetics, and brain function of BPD is lacking. MicroRNA-124-3p (miR-124-3p) was recently identified in a Genome-Wide Association Study as likely associated with BPD. Here, we identified the anatomical brain expression of genes likely modulated by miR-124-3p and compared morphometry in those brain regions in BPD inpatients vs. controls matched for psychiatric comorbidities. We isolated lists of targets likely modulated by miR-124-3p from TargetScan (v 8.0) by their preferentially conserved targeting (Aggregate PCT > 0.99, see Supplementary Table 1). We applied Process Genes List (PGL) to identify regions of interest associated with the co-expression of miR-124-3p target genes. We compared the gray matter volume of the top region of interest co-expressing those genes between BPD inpatients (n = 111, 46% female) and psychiatric controls (n = 111, 54% female) at The Menninger Clinic in Houston, Texas. We then correlated personality measures, suicidal ideation intensity, and recovery from suicidal ideation with volumetrics. Gene targets of miR-124-3p were significantly co-expressed in the left Globus Pallidus (GP), which was smaller in BPD than in psychiatric controls. Smaller GP volume was negatively correlated with agreeableness and with recovery from suicidal ideation post-treatment. In BPD, GP volume may be reduced through miR-124-3p regulation and suppression of its target genes. Importantly, we identified that a reduction of the GP in BPD could serve as a potential biomarker for recovery from suicidal ideation.

Leading improvement at scale in healthcare: Sir John Oldham.

BACKGROUND: When I became senior partner at my general practice I undertook a part time MBA at Manchester Business School in the late 90s to learn the things medical school hadn't taught me; organizational design and behaviour, finance, strategic management and human resources (as it was then called). My dissertation was on quality methods in other industries that could be applied in healthcare. JOURNEY: We tried out total quality management methods in my practice and began to demonstrably improve care, services and the use of resources. I titled this in presentations in the early noughties the Quality Trinity, which morphed into the now widely adopted triple aim. The practice won awards and I became a sessional advisor to the Dept of Health. I was invited to Boston by Don Berwick and saw the collaborative method of improvement. When a new Government came to power pledging to improve quality I designed a means of using the collaborative for large scale change. This opened a parallel career in quality improvement for the next 20 years, though I continued to be a practicing GP for the majority of that. REFLECTIONS: When I started there was literature on total quality management in other industries but very little in healthcare, and nothing on large scale change. The methods challenged orthodoxy about how you changed healthcare delivery and met resistance, even hostility. Much that was suspect is now embraced, techniques that were unheard of are now common and the literature is expanding. This article gives experiential insight into large scale change gathered in my career that I hope may help others now charged with these tasks.

Personality trait domains predict psychiatric symptom and functional outcomes.

A review of high intensity, high dose mentalization-based inpatient psychiatric treatment indicated large effect-size reductions in symptoms of depression, anxiety, somatization, and improving emotion-regulation functioning (Allen et al., 2017). This study examined the impact of pathological personality traits has on baseline symptoms and functioning, as well as their impact on the longitudinal course in a large cohort of adult inpatient psychiatric sample (N = 804). The Personality Inventory for DSM-5 (PID-5; Krueger et al., 2012) was used to assess trait domains impact on longitudinal outcomes (anxiety, depression, somatic symptoms, and functional impairment) using hierarchical repeated measures modeling. Results indicate Negative Affectivity and Detachment were related to higher admission severity in all four outcome domains. Psychoticism was related to somatic symptoms, while Antagonism and Disinhibition were related to functional impairment. Paradoxically, when symptoms were plotted over 2-week intervals during hospitalization, patients with higher admission PID-5 trait scores exhibited greater improvement over time. The PID-5 appears to contribute to prediction of treatment outcome response above and beyond demographic and burden of illness. Importantly, the findings add to a growing body of literature indicating that impairments in personality traits do not preclude positive treatment response, particularly when treatments target pathological personality features. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Attitudes of UK veterinary students towards careers in the production animal sector: A mixed methods approach.

BACKGROUND: Within the production animal sector, it has long been forecast that demand for veterinary services could outstrip supply. This study aims to identify factors influencing veterinary undergraduates' attitudes towards a career in farm animal veterinary practice and how those factors may be influenced by their experiences during their time as an undergraduate. METHODS: An online survey was distributed to all vet schools in the UK and Ireland. Thematic analysis and descriptive data analysis were performed on the 1146 responses received. RESULTS: Seven themes were identified: relationships, preferences and interest, fit, direct experience, fear, ethics and values and lifestyle. When considering first job choice, extra mural studies (EMS) and personal interest (60% and 75% of respondents respectively) were very influential. Factors that appeal or put off respondents from a career in farm animal varied dependent on anticipated first job (p < 0.001), but working hours and out of hours were consistently identified as barriers. CONCLUSION: The results highlight the importance of EMS being more transparent about the profession and using the opportunity to discuss undergraduate concerns regarding farm animal practice.

Diagnostic accuracy of DSM-5 borderline personality disorder criteria: Toward an optimized criteria set.

OBJECTIVE: The polythetic system used by the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) for diagnosing borderline personality disorders (BPD) is far from optimal; however, accumulated research and clinical data are strong enough to warrant ongoing utilization. This study examined diagnostic efficiency of the nine DSM-IV BPD criteria, then explored the feasibility of an optimized criteria set in classifying BPD. METHODS: Adults (N=1,623) completed the Structured Clinical Interviews for DSM-IV Axis II Disorders resulting in a BPD group (n=352) and an inpatient psychiatric control group (PC) with no personality disorders (n=1,271). Receiver operator characteristics and diagnostic efficiency statistics were calculated to ascertain the relative diagnostic efficiency of each DSM-5 BPD criterion in classifying BPD cases. RESULTS: Affective instability (Criterion 6) evidenced the strongest capacity to differentiate the groups (AUC = .84, SE = .01, p < .0001). Abandonment fears (Criterion 1), unstable relationships (Criterion 2), identity disturbance (Criterion 3), impulsivity (Criterion 4), and chronic emptiness (Criterion 7) yielded good-to-moderate discrimination (AUC range = .75-.79). A composite index of these six criteria yielded excellent accuracy (AUC = .98, SE = .002, p < .0001), sensitivity (SN=.99), and specificity (SP=.90). CONCLUSIONS: The current findings add to evidence that affective instability is a useful gate criterion for screening, and the optimized criteria set evidences equivalent accuracy to the original 9 criteria, with a substantial reduction in estimated heterogeneity (from 256 combinations with the original set to 42 combinations with the optimized set).

Shotgun proteomic analysis of yeast-elicited California poppy (Eschscholzia californica) suspension cultures producing enhanced levels of benzophenanthridine alkaloids.

The California poppy, Eschscholzia californica, produces benzophenanthridine alkaloids (BPAs), an important class of biologically active compounds. Cell cultures of E. californica were investigated as an alternative and scalable method for producing these valuable compounds; treatment with yeast extract increased production from low levels to 23 mg/g dry weight (DW) of BPAs. A shotgun proteomic analysis of E. californica cell cultures was undertaken to explore changes in metabolism associated with enhanced BPA production. We implemented differential centrifugation and then shotgun proteomics based on nanoliquid chromatography/mass spectrometry (nano-LC-MS/MS) for peptide separation and analysis. A unigene database available for E. californica was translated and utilized for protein identification. Approximately 646 proteins (3% false discovery rate at the protein level) were identified. Differentially abundant proteins observed with elicitation included enzymes involved in (S)-adenosyl methionine (SAM) biosynthesis and BPA biosynthesis. These results demonstrate (1) the identification of proteins from a medicinal plant using shotgun proteomics combined with a well-annotated, translated unigene database and (2) the potential utility of proteomics for exploring changes in metabolism associated with enhanced secondary metabolite production.