Qualitative Analysis of Attitudes Toward Adult-Child Sexual Activity Among Minor-Attracted Persons.

This study uses qualitative methodology to explore narrative responses to a question regarding the harmful versus beneficial effects of adult-child sex on children. Data were gathered from a survey of self-identified minor-attracted persons (MAPs). Two hundred and sixty-seven survey participants provided narrative responses. Results indicated a significant amount of variability in perceptions of harm and of mitigating or aggravating factors. Understanding the subjective perspectives of MAPs, the range of their attitudes, and the issues that they identify as pertinent is critically important for clinical efficacy in the treatment of pedophilia.

Entrapment as a mediator of suicide crises.

BACKGROUND: Prior research has validated the construct of a suicide crisis syndrome (SCS), a specific psychological state that precedes and may precipitate suicidal behavior. The feeling of entrapment is a central concept of the SCS as well as of several other recent models of suicide. However, its exact relationship with suicidality is not fully understood. In efforts to clarify the exact role of entrapment in the suicidal process, we have examined if entrapment mediates the relationship of other components of the SCS, including ruminative flooding, panic-dissociation, fear of dying and emotional pain, with suicidal ideation (SI) in recently hospitalized psychiatric inpatients. METHODS: The Suicide Crisis Inventory (SCI) and Beck Scale for Suicidal Ideation (BSS) were administered to 200 high-risk adult psychiatric inpatients hospitalized following SI or suicide attempt, assessing SCS and SI levels at admission, respectively. The possible mediation effects of entrapment on the relationship between the other components of the SCS and SI at admission were evaluated. RESULTS: Entrapment significantly and fully mediated the relationship of ruminative flooding, panic-dissociation, and fear of dying with SI, with no direct relationships between these variables and SI reaching statistical significance. Further, no reverse mediation relationships between these variables and SI were found, indicating that the mediation effects of entrapment were unidirectional. While entrapment did mediate the association between emotional pain and SI, the direct relationship between emotional pain and SI was also significant. Moreover, in reverse mediational analysis, emotional pain was a partial mediator of the relationship between entrapment and SI. CONCLUSION: Entrapment and emotional pain may have a more direct association with SI than the other components of the SCS, including ruminative flooding, panic-dissociation, and fear of dying, the effects of which are mediated by the former. This suggests entrapment and emotional pain may represent key symptomatic targets for intervention in acutely suicidal individuals. Further research is needed to determine the relationship of these constructs to suicidal behavior.

Clinicians' conflicting emotional responses to high suicide-risk patients-Association with short-term suicide behaviors: A prospective pilot study.

BACKGROUND: Clinician's emotional responses to patients have been recognized as potentially relating to treatment outcome, however they have received little attention in the literature on suicide risk. We examine the relationship between a novel targeted measure of clinicians' emotional responses to high-risk psychiatric inpatients and their short-term post-discharge suicide behavior. METHODS: First-year psychiatry residents' emotional responses to their patients were assessed anonymously with the novel self-report 'Therapist Response Questionnaire-Suicide Form' (TRQ-SF). Patient outcomes were assessed at 1-2months post-discharge, and post-discharge suicide outcomes were assessed with the Columbia Suicide Severity Rating Scale. Following exploratory factor analysis of the TRQ-SF, scores on the resultant factors were examined for relationships with clinical and demographic measures and post-discharge suicide behavior. RESULTS: A two-factor model fit the data, with factors reflecting dimensions of affiliation/rejection and distress/non-distress. Two items that did not load robustly on either factor had face validity for hopefulness and hopelessness and were combined as a measure along a hopefulness/hopelessness dimension. The interaction Distress×Hopefulness, reflecting a conflicting emotional response pattern, significantly predicted post-discharge suicide outcomes even after covarying for depression, entrapment, and suicidal ideation severity. CONCLUSION: Clinicians' conflicting emotional responses to high-risk patients predicted subsequent suicidal behavior, independent of traditional risk factors. Our findings demonstrate the potential clinical value of assessing such responses.

Increased sleep duration precedes the improvement of other symptom domains during the treatment of acute mania: a retrospective chart review.

BACKGROUND: Understanding trajectories of symptom changes may help gauge treatment response and better identify therapeutic targets in treatment of acute mania. We examined how symptoms of sleep disturbance, mania, and psychosis resolved in a naturalistic treatment setting, hypothesizing that improvement in sleep would precede improvement in manic and psychotic symptoms. METHODS: Charts of 100 patients with admitting diagnoses of bipolar mixed or manic episode were retrospectively reviewed. Medications and demographic variables were recorded, and the Clinician-Administered Rating Scale for Mania (CARS-M) mania and psychosis ratings and sleep hours were determined for 8 observation points. Times to minimum symptom level in each domain were compared via Wilcoxon signed-rank tests. Symptom correlations and trajectories and medication effects were explored using repeated measures ANOVA and regression models. RESULTS: Manic and psychotic symptom resolution was linear over the time of hospitalization. In contrast, sleep showed a slow initial response, followed by rapid increase to peak, preceding peak improvement in mania and psychosis (p < 0.001). Rate of sleep restoration was a predictor of rate but not of magnitude of treatment response for symptoms mania and psychosis. Patterns of medication use did not affect symptom trajectories. CONCLUSIONS: In acute mania, improvement in sleep with treatment is dissociable from resolution in symptoms of mania and psychosis, but there appears to be no therapeutic advantage to patient oversedation. Sleep improves first and may be both a predictor of the rate of treatment response and a useful therapeutic target.

A Pilot Study of Safety and Efficacy of Cranial Electrotherapy Stimulation in Treatment of Bipolar II Depression.

This double-blind, sham-controlled study sought to investigate the effectiveness of cranial electrotherapy stimulation (CES) for the treatment of bipolar II depression (BD II). After randomization, the active group participants (n = 7) received 2 mA CES treatment for 20 minutes five days a week for 2 weeks, whereas the sham group (n = 9) had the CES device turned on and off. Symptom non-remitters from both groups received an additional 2 weeks of open-label active treatment. Active CES treatment but not sham treatment was associated with a significant decrease in the Beck Depression Inventory (BDI) scores from baseline to the second week (p = 0.003) maintaining significance until week 4 (p = 0.002). There was no difference between the groups in side effects frequency. The results of this small study indicate that CES may be a safe and effective treatment for BD II suggesting that further studies on safety and efficacy of CES may be warranted.

Fear of dying in panic attacks predicts suicide attempt in comorbid depressive illness: prospective evidence from the National Epidemiological Survey on Alcohol and Related Conditions.

CONTEXT: As a group, comorbid anxiety disorders among depressed persons have consistently been found to increase risk of suicide attempt (SA). Growing evidence supports the link between panic attacks (PAs) and suicidality, but prospective evidence is limited and the nature of the linkage remains unclear. The positive-feedback model of suicide suggests that PAs eliciting catastrophic cognitions may drive SA. OBJECTIVE: To prospectively examine the relationship between PAs, panic symptoms and suicidality in individuals meeting DSM-IV criteria for past-year major depressive episodes in a large epidemiological study. METHODS: In data on 2,864 participants of the National Epidemiological Survey on Alcohol and Related Conditions (NESARC) wave 1 and 2 surveys with depressive disorders, the associations of PAs and panic symptoms with subsequent suicidal ideation (SI) and SAs were assessed using logistic regression. RESULTS: Past-year PAs in wave 1 significantly increased odds for subsequent SI and attempt in the 3-year follow-up interval; however, in multivariate analyses, PAs were not a significant predictor, but PAs featuring fear of dying were. Further, among subjects with PAs, fear of dying during a PA increased the odds of subsequent SA sevenfold, even after controlling for comorbid disorders, demographic factors, and other PA symptoms. CONCLUSION: PAs characterized by prominent morbid catastrophic cognitions may mediate the transition to SIs and SAs in subjects with depressive episodes. Presence of these symptoms in clinical settings may serve as a warning sign for future suicidality.

Distinctive emotional responses of clinicians to suicide-attempting patients--a comparative study.

BACKGROUND: Clinician responses to patients have been recognized as an important factor in treatment outcome. Clinician responses to suicidal patients have received little attention in the literature however, and no quantitative studies have been published. Further, although patients with high versus low lethality suicidal behaviors have been speculated to represent two distinct populations, clinicians' emotional responses to them have not been examined. METHODS: Clinicians' responses to their patients when last seeing them prior to patients' suicide attempt or death were assessed retrospectively with the Therapist Response/Countertransference Questionnaire, administered anonymously via an Internet survey service. Scores on individual items and subscale scores were compared between groups, and linear discriminant analysis was applied to determine the combination of items that best discriminated between groups. RESULTS: Clinicians reported on patients who completed suicide, made high-lethality attempts, low-lethality attempts, or died unexpected non-suicidal deaths in a total of 82 cases. We found that clinicians treating imminently suicidal patients had less positive feelings towards these patients than for non-suicidal patients, but had higher hopes for their treatment, while finding themselves notably more overwhelmed, distressed by, and to some degree avoidant of them. Further, we found that the specific paradoxical combination of hopefulness and distress/avoidance was a significant discriminator between suicidal patients and those who died unexpected non-suicidal deaths with 90% sensitivity and 56% specificity. In addition, we identified one questionnaire item that discriminated significantly between high- and low-lethality suicide patients. CONCLUSIONS: Clinicians' emotional responses to patients at risk versus not at risk for imminent suicide attempt may be distinct in ways consistent with responses theorized by Maltsberger and Buie in 1974. Prospective replication is needed to confirm these results, however. Our findings demonstrate the feasibility of using quantitative self-report methodologies for investigation of the relationship between clinicians' emotional responses to suicidal patients and suicide risk.

Impact of the Abbreviated Suicide Crisis Syndrome Checklist on Clinical Decision Making in the Emergency Department.

Objective: The suicide crisis syndrome (SCS), an acute negative affect state predictive of near-term suicidal behavior, is currently under review for inclusion as a suicide-specific diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM). While the predictive validity of the SCS for near-term suicidal behavior is well documented, its real-world clinical utility has yet to be evaluated. As such, this study evaluated how implementation of a novel assessment tool, the Abbreviated SCS Checklist (A-SCS-C), into the electronic medical records (EMRs) influenced disposition decisions in the emergency departments (EDs) of a large urban health system.Methods: Logistic regression analyses evaluated the impact of SCS diagnosis on 212 admission/discharge decisions after accounting for chief complaints of suicidal ideation (SI), suicidal behavior (SB), and psychosis/agitation.Results: The A-SCS-C was concordant with 86.9% of all non-psychotic disposition decisions. In multivariable analysis, the A-SCS-C had an adjusted odds ratio (AOR) of 65.9 (95% confidence interval: 18.79-231.07) for inpatient admission, whereas neither suicidal ideation nor behavior was a significant predictor. The effect size remained very high in 3 sensitivity analyses, the first using information from a different section of the EMR, the second in patients younger than 18 years, and the third in males and females separately (AORs > 30).Conclusions: SCS diagnosis, when implemented in ED EMRs alongside SI and SB, was strongly predictive of clinician decision making with regard to admission/discharge, particularly in non-psychotic patients, while SI and SB were noncontributory. Overall, our results show that the SCS, as a diagnostic entity, demonstrates robust clinical utility and may reduce the limitations of relying on self-reported SI as a primary basis of suicide risk assessment.

Predictive validity and symptom configuration of proposed diagnostic criteria for the Suicide Crisis Syndrome: A replication study.

OBJECTIVE: The Suicide Crisis Syndrome (SCS) is a new proposed suicide-specific diagnosis. In the present large replication study, we examine SCS diagnostic criteria to determine which configuration of symptoms demonstrates the strongest convergent and predictive validity for near-term suicidal behaviour. METHODS: We conducted confirmatory factor analysis (CFA) to examine the factor structure of the proxy-SCS variables derived from an extensive self-report test battery and administered to 903 psychiatric patients (age (M = 36.70, SD = 13.91); gender (64.0% female)) at intake and 4-8-week follow-up assessments. Convergent and predictive validity of five configurations of the proposed SCS diagnostic criteria for suicidal ideation (SI) and attempts (SA) were examined using regression analyses. The new clinician-rated SCS-Checklist was piloted with 68 participants. RESULTS: Both the one-factor and the five-factor models of proxy-SCS variables exhibited strong model fit, supporting the uni-dimensionality as well as the five-criteria structure of the SCS. All four configurations were uniquely related to the presence of a suicide attempt at follow-up when controlling for intake SI, lifetime SA, age, and gender, but none were significantly associated with intake SA when controlling for intake SI, age, and gender. All bivariate correlations between proxy-assessed and checklist-assessed SCS symptom configurations were significant and positive. CONCLUSION: The proposed five-symptom structure of the SCS diagnostic criteria was supported and appears to describe a clinically meaningful syndrome specifically related to near-term suicidal behaviour. SCS assessment may significantly improve clinical evaluation of imminent suicide risk. Future studies are needed to assess the utility of the syndrome in clinical settings.

Predictors of patient and caregiver distress in an adult sample with bipolar disorder seeking family treatment.

Little is known about the potentially unique sources of distress in populations seeking family-oriented treatment for bipolar disorder. The present study aimed to characterize this new treatment population by measuring depression, anxiety, quality of life, knowledge of bipolar disorder, therapeutic alliance, and mental illness stigma in 43 bipolar patients and 41 caregivers at family treatment intake. In all, 50% of patients and 27.6% of caregivers had significant depressive symptoms, whereas 51.2% of patients and 45.5% of caregivers had significant anxiety symptoms. Caregiver anxiety was inversely related to patient anxiety, stigma, and poor alliance. Treatment nonadherence was associated with more anxiety and stigma in patients and less anxiety in caregivers. In summary, family-oriented bipolar treatment seekers are significantly distressed at intake, and may benefit from lowering anxiety and stigma in patients and raising awareness and concern in caregivers. Future research should further clarify the complex relationships between caregiver and patient symptoms and attitudes.

Suicidality and Cannabidiol: Opportunities and Challenges.

Cannabidiol (CBD) is gaining considerable attention in the research community with promising results in a variety of neuropsychiatric conditions. In particular, there are replicated findings for the therapeutic effects of CBD on psychotic and anxiety symptoms as well as substance use disorders, all of which are highly prevalent in patients who present with suicidality. Meanwhile, there has been a lack of suicide research on cannabidiol. This perspective provides an overview of the available evidence, potential reasons behind the halt in suicide research on cannabidiol, and recommendations for future investigations.

Construct development: The Suicide Trigger Scale (STS-2), a measure of a hypothesized suicide trigger state.

BACKGROUND: This study aims to develop the construct of a 'suicide trigger state' by exploring data gathered with a novel psychometric self-report instrument, the STS-2. METHODS: The STS-2, was administered to 141 adult psychiatric patients with suicidal ideation. Multiple statistical methods were used to explore construct validity and structure. RESULTS: Cronbach's alpha (0.949) demonstrated excellent internal consistency. Factor analyses yielded two-component solutions with good agreement. The first component described near-psychotic somatization and ruminative flooding, while the second described frantic hopelessness. ROC analysis determined an optimal cut score for a history of suicide attempt, with significance of p < 0.03. Logistic regression analysis found items sensitive to history of suicide attempt described ruminative flooding, doom, hopelessness, entrapment and dread. CONCLUSIONS: The STS-2 appears to measure a distinct and novel clinical entity, which we speculatively term the 'suicide trigger state.' High scores on the STS-2 associate with reported history of past suicide attempt.

A comparison of low-dose risperidone to paroxetine in the treatment of panic attacks: a randomized, single-blind study.

BACKGROUND: Because a large proportion of patients with panic attacks receiving approved pharmacotherapy do not respond or respond poorly to medication, it is important to identify additional therapeutic strategies for the management of panic symptoms. This article describes a randomized, rater-blind study comparing low-dose risperidone to standard-of-care paroxetine for the treatment of panic attacks. METHODS: Fifty six subjects with a history of panic attacks were randomized to receive either risperidone or paroxetine. The subjects were then followed for eight weeks. Outcome measures included the Panic Disorder Severity Scale (PDSS), the Hamilton Anxiety Scale (Ham-A), the Hamilton Depression Rating Scale (Ham-D), the Sheehan Panic Anxiety Scale-Patient (SPAS-P), and the Clinical Global Impression scale (CGI). RESULTS: All subjects demonstrated a reduction in both the frequency and severity of panic attacks regardless of treatment received. Statistically significant improvements in rating scale scores for both groups were identified for the PDSS, the Ham-A, the Ham-D, and the CGI. There was no difference between treatment groups in the improvement in scores on the measures PDSS, Ham-A, Ham-D, and CGI. Post hoc tests suggest that subjects receiving risperidone may have a quicker clinical response than subjects receiving paroxetine. CONCLUSION: We can identify no difference in the efficacy of paroxetine and low-dose risperidone in the treatment of panic attacks. Low-dose risperidone appears to be tolerated equally well as paroxetine. Low-dose risperidone may be an effective treatment for anxiety disorders in which panic attacks are a significant component. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT100457106.

Structural differences within negative and depressive syndrome dimensions in schizophrenia, organic brain disease, and major depression: A confirmatory factor analysis of the positive and negative syndrome scale.

OBJECTIVE: The emerging dimensional approach to classification and treatment of psychiatric disorders calls for better understanding of diagnosis-related variations in psychiatric syndromes and for proper validation of psychometric scales used for the evaluation of those syndromes. This study tested the hypothesis that negative and depressive syndromes as measured by the Positive and Negative Syndrome Scale (PANSS) are consistent across different diagnoses. METHOD: We administered the PANSS to subjects with schizophrenia (n = 305), organic brain disease (OBD, n = 66) and major depressive disorder (MDD, n = 75). Confirmatory factor analysis (CFA) was used to establish if the PANSS items for negative symptoms and for depression fit the hypothesized factor structure and if the item factor loadings were similar among the diagnostic groups. RESULTS: The negative and depressive symptom subscales fit well according to a variety of fit indexes for all groups individually after some modest model modification. However, multisample modeling procedures indicated that the pattern of factor loadings was significantly different among the groups in most cases. CONCLUSION: The results of this study indicate diagnosis-related variations in the negative and depressive syndrome dimensions in schizophrenia, OBD and MDD. These results also validate limited use of the PANSS for evaluation of negative and depressive syndromes in disorders other than schizophrenia. Larger studies are warranted to further evaluate clinical and nosologic significance of diagnostic categories, dimensions and structures of psychiatric syndromes.

Ensuring research competency in psychiatric residency training.

OBJECTIVE: This article discusses the importance of research training in psychiatric residency programs and makes recommendations for enhancement. METHODS: The authors examine the literature detailing the shortage of psychiatrist-researchers and the limitations of research training during residency. The authors then describe the Psychiatrists Acquiring Research Training (PART) program at Beth Israel Medical Center that attempts to address this problem. Data collected on resident scholarly activity, including publications and presentations, is presented. RESULTS: Since its inception, all scholarly activities have increased under the PART program. The 89 residents, followed over 5 academic years, co-authored 32 publications, gave 56 presentations, and received prestigious honors such as NIMH fellowships and national research awards. CONCLUSION: Residents' participation in research has been advanced through participation in PART. Ensuring research competency among all psychiatrists is crucial to providing the best science-based care; PART represents a cost-effective way to integrate research training with psychiatric residency. The authors also discuss opportunities and obstacles to developing research programs as part of psychiatric residency training.

The Relevance of Sex in the Association of Synthetic Cannabinoid Use With Psychosis and Agitation in an Inpatient Population.

BACKGROUND: Current evidence suggests that women are more sensitive to the effects of cannabinoids. The aim of this study was to investigate the relevance of sex in the association of synthetic cannabinoid (SC) use with psychosis and agitation. METHODS: A retrospective chart review was conducted for patients admitted to a psychiatric unit (2014-2016) to extract information on demographic factors, use of substances, clinical symptoms, and pharmacologic treatments. Study groups were defined as SC users (anyone who reported use of SCs over the past 3 months), cannabis users (positive toxicology screen for Δ9-tetrahydrocannabinol [THC]), and controls (those who denied use of SCs over the past 3 months and had negative toxicology for THC). RESULTS: Digital charts of 983 patients were reviewed. A total of 162 subjects reported use of SCs over the past 3 months (76% male), and 292 subjects had positive toxicology screen for THC (67% male). A total of 38.9% of SC users (n = 63) had positive urine toxicology screen for THC. SC users had higher risks of psychotic presentations (adjusted odds ratio [AOR] = 3.390; 95% CI, 1.390-8.267) and agitation (AOR = 4.643; 95% CI, 1.974-10.918) compared to the controls. While women had lower rates of psychosis than men in the cannabis and control groups, the rates were markedly potentiated with SC use to high levels (79%) approximately equal to that seen in men (80%). There was also a significant interaction between SC use and sex for agitation (AOR = 0.308; 95% CI, 0.117-0.808). Female SC users were significantly more agitated than male SC users (73.7% vs 47.6%, respectively, P = .005). CONCLUSIONS: SC users are more likely than nonusers to be psychotic or agitated in an inpatient setting. The potentiated rates of psychosis and agitation with SC use in women suggest that they may have a greater sensitivity to these synthetic compounds.​.

Abnormal heat and pain perception in remitted heroin dependence months after detoxification from methadone-maintenance.

Patients receiving methadone maintenance therapy (MMT) for opiate dependence have altered nociception, complicating analgesic treatment. Increasing numbers of patients are choosing opiate-free treatment programs, yet data on the course of this abnormality months after detoxification from methadone is contradictory and based exclusively on cold pressor experiments. Heat and pain thresholds were measured by quantitative sensory testing (QST) in 23 subjects with heroin dependence in full, sustained remission months after detoxification from methadone and 27 healthy non-drug using controls. Self reports of pain intensity and unpleasantness were also collected. Test scores were compared across groups and correlated with measures of drug use history. There were significant differences between remitted opiate-dependent subjects and controls on the measures of heat threshold (38.83 vs. 35.96; Mann-Whitney U=177.5, p=0.006), and the measure of pain threshold (48.73 vs. 47.62; Mann-Whitney U=217.5, p=0.043). There was no correlation of any measure of drug use history with the heat or pain experience. Abstinent, formerly opioid-dependent patients continue to demonstrate abnormal noxious perception months after detoxification from methadone.

Comparison of personality traits in pedophiles, abstinent opiate addicts, and healthy controls: considering pedophilia as an addictive behavior.

To investigate the model of pedophilia as a disorder of addictive behavior, pedophiles and chemically addicted individuals were compared on personality traits potentially associated with impaired behavioral inhibition. Twenty-nine pedophiles, 25 opiate addicts (OA's), and 27 healthy controls were administered the Barratt Impulsivity Scale, Hare Psychopathy Checklist-Revised (PCL-R), and Structured Clinical Interview for DSM-V for Axis-II. OA's scored higher than either pedophiles or controls on the Barratt. Pedophiles and OA's scored higher than controls on all 3 Psychopathy Checklist-Revised scores but OA's scored marginally higher than pedophiles on factor 2 (behavioral) and total scores. On Structured Clinical Interview for DSM-V for Axis-II, pedophiles scored higher than controls on paranoid and schizoid scores whereas OA's did so on paranoid scores. Thus, both pedophiles and OA's may have elevated psychopathic traits and propensity toward cognitive distortions, as reflected in cluster A traits. Such similarities support the conceptualization of pedophilia as a behavioral addiction. Pedophiles may be less impulsive than OA's, however, and more prone toward cognitive distortions.

Whether Called Acute Suicidal Affective Disturbance or Suicide Crisis Syndrome, a Suicide-specific Diagnosis Would Enhance Clinical Care, Increase Patient Safety, and Mitigate Clinician Liability.

Separate research groups have independently argued the need for a suicide-specific diagnosis within the psychiatric diagnostic nomenclature. Although a suicide-specific diagnosis could possibly enhance clinical care and improve patient safety, some clinicians have expressed concerns regarding the legal risk of utilizing a suicide-specific diagnosis. In this column, the first of a 2-part series exploring the potential risks and benefits of a suicide-specific diagnosis, the authors draw from their decades of experience in clinical work, legal consulting, as well as the litigation of suicide and wrongful death lawsuits and contend that the bona fide use of a suicide-specific diagnosis would mitigate legal liability to clinicians.

Cerebral metabolism and mood in remitted opiate dependence.

BACKGROUND: Opiate-dependent individuals are prone to dysphoria that may contribute to treatment failure. Methadone-maintenance therapy (MMT) may mitigate this vulnerability, but controversy surrounds its long-term use. Little is known about the neurobiology of mood dysregulation in individuals receiving or removed from MMT. METHODS: Fifteen opiate-abstinent and 12 methadone-maintained, opiate-dependent subjects, who lacked other Axis I pathology, and 13 control subjects were compared on the Cornell Dysthymia Rating Scale (CDRS) and regional cerebral glucose metabolism (rCMRglc) using [(18)F]fluorodeoxyglucose positron emission tomography. RESULTS: CDRS scores showed no group differences. Opiate-abstinent subjects had lower rCMRglc than control subjects in the bilateral perigenual anterior cingulate cortex (ACC), left mid-cingulate cortex, left insula and right superior frontal cortex. Methadone-maintained subjects exhibited lower rCMRglc than control subjects in the left insula and thalamus. In opiate-abstinent subjects, rCMRglc in the left perigenual ACC and mid-cingulate cortex correlated positively with CDRS scores. CONCLUSIONS: In remitted heroin dependence, opiate-abstinence is associated with more widespread patterns of abnormal cortical activity than MMT. Aberrant mood processing in the left perigenual ACC and mid-cingulate cortex, seen in opiate-abstinent individuals, is absent in those receiving MMT, suggesting that methadone may improve mood regulation in this population.