An Orientation to Aviation Psychiatry: With 30 Case Examples and a 10-Year Follow-up.

ABSTRACT: This report orients general psychiatrists to assessment and care for "safety sensitive" aviation workers. Our case study of 30 sequential aviation patients consists of demographic, clinical, and aviation characteristics plus a 10-year follow-up. Relatively few pilots and other aviation workers self-identified their psychiatric condition. Aviation outcomes associated with psychiatric disorder included personnel injury and/or aircraft damage (three cases), imminent risk without injury or damage (nine cases), impaired aviation functioning without imminent risk (15 cases), and neither risk nor psychiatric disorder or impairment (three cases). Mood, anxiety, and substance use disorders comprised the most common diagnoses. Ten years later, 23 patients were employed (21 in aviation); seven were disabled or deceased. General psychiatrists will find aviation cases clinically familiar but requiring added evaluation for aviation safety and potential interaction with the Federal Aviation Agency and airline supervisors.

Alcohol Craving and Psychiatric Disorders Among Current Drinkers.

BACKGROUND AND OBJECTIVES: Previous research has shown that alcohol craving is associated with psychiatric comorbidities. However, no population studies have examined the odds of psychiatric disorders in cravers and noncravers. The purpose of this study was to investigate current prevalence rates and odds ratios of psychiatric disorders among alcohol drinkers with and without alcohol craving in a population-based sample. We also compared four craving groups (cravers with and without alcohol use disorder [AUD], noncravers with and without AUD) for psychiatric comorbidities. METHODS: The study data were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). A subset of the NESARC sample (N = 22 000) who reported alcohol use during the past 12 months was included. Prevalence rates of psychiatric disorders were compared among current drinkers with alcohol craving (N = 900) and without alcohol craving (N = 21 500). RESULTS: Cravers had higher prevalence rates of current psychiatric disorders than noncravers. Even after adjustment for other psychiatric disorders including AUD, cravers had significantly higher odds of any substance use disorder (adjusted odds ratio [AOR], 9.01), any mood disorder (AOR, 1.78), any anxiety disorder (AOR, 1.86), and any personality disorder (AOR, 1.92) than noncravers. Interestingly, cravers without AUD had even higher rates of any anxiety disorder and any personality disorder than noncravers with AUD. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: Alcohol craving is associated with a higher prevalence of various psychiatric disorders. These findings suggest that alcohol craving may be related to transdiagnostic features that are present across various psychiatric disorders. (Am J Addict 2021;30:34-42).

Identifying, Assessing, and Treating Korsakoff Syndrome Patients: Updated Perspectives.

ABSTRACT: Objectives consist of updating published reports on the recognition, assessment, and care of patients with Wernicke-Korsakoff syndrome (WKS). Methods included defining relevant terms, describing core clinical phenomena, conducting meaningful reviews for latter-day WKS publications, and selecting instructive case examples. Findings covered epidemiology, precipitants, neuroimaging studies, alternate learning strategies in WKS, adjunctive treatments, and promising research. In conclusion, patients, their family members, clinicians, and public health experts should benefit from this updated knowledge. Countries with substantial alcohol consumption should consider emulating Holland in designating WKS research centers, founding regional clinical facilities, and funding multidisciplinary expert teams.

Zolpidem-Associated Consequences: An Updated Literature Review With Case Reports.

A post-2000 literature search reviewed prevalence of health consequences associated with zolpidem, plus two salient case reports. Common zolpidem-related harms encompassed accidents, falls, overdoses, delirium, and infections. Risks to others included assaults, vehicular accidents, various crimes, and civil actions that occurred during zolpidem-induced delirium, withdrawal, and other impediments. Remarkably, much harm occurred while patients were taking therapeutic doses of licitly prescribed zolpidem (10-30 mg). Zolpidem-associated health, behavioral, and social problems comprise an international pandemic of preventable heath misfortunes.

Call for "High-Dose" Olanzapine Research in Treatment-Resistant Psychosis.

Psychiatric care has entered a new era in which care for treatment-resistant psychiatric disorder has attained priority status. Addressing treatment resistance involves 1) alleviating symptoms and signs of the diagnostic condition, 2) returning the patient to functional capacity, and 3) preventing subsequent recurrence. This approach has achieved considerable momentum in regard to major depressive disorder, as evidenced by early recognition and timely treatment, medication augmentation strategies, mind-body training for the populace at large, effective and efficient psychotherapies, and new biomedical interventions. This report proposes a pharmacotherapy that may qualify for treatment-resistant psychosis, that is, high-dose olanzapine. Considerable thought, planning, resources, and effort would be necessary to test this intervention. This proposal includes suggestions for developing an affordable means of assessing this and future candidates for treatment-resistant psychosis.

Methadone-Related Delirium: Prevalence, Causes, and Outcomes.

Goals consist of determining 5-year prevalence and recurrence of methadone-related delirium (MRD), along with causes, treatments, and outcomes. Sample comprised 81 patients in methadone maintenance treatment. Criteria for MRD encompassed delirium with high methadone serum levels plus alleviation of delirium upon lowering methadone serum levels. MRD occurred in 14 cases who had 25 episodes. MRD precipitants included physician prescribing (i.e., excessive methadone or medications slowing methadone metabolism), drug misuse, and renal-fluid alterations. Social affiliation (housing with family, intimate partner) reduced MRD; employment increased MRD. Recovery occurred in 23/25 episodes of MRD; two episodes progressed to dementia. Obtaining serum methadone levels fostered prompt recognition.

Feasibility, acceptability and clinical utility of the Cultural Formulation Interview: mixed-methods results from the DSM-5 international field trial.

BackgroundThere is a need for clinical tools to identify cultural issues in diagnostic assessment.AimsTo assess the feasibility, acceptability and clinical utility of the DSM-5 Cultural Formulation Interview (CFI) in routine clinical practice.MethodMixed-methods evaluation of field trial data from six countries. The CFI was administered to diagnostically diverse psychiatric out-patients during a diagnostic interview. In post-evaluation sessions, patients and clinicians completed debriefing qualitative interviews and Likert-scale questionnaires. The duration of CFI administration and the full diagnostic session were monitored.ResultsMixed-methods data from 318 patients and 75 clinicians found the CFI feasible, acceptable and useful. Clinician feasibility ratings were significantly lower than patient ratings and other clinician-assessed outcomes. After administering one CFI, however, clinician feasibility ratings improved significantly and subsequent interviews required less time.ConclusionsThe CFI was included in DSM-5 as a feasible, acceptable and useful cultural assessment tool.

Long QTc During Methadone Maintenance: Contributors and Interventions Over 4 Years.

Our goal consisted of describing the 4-year prevalence, contributors, and interventions for long QTc's in methadone maintenance treatment. Cardiologists' diagnosis of long QTc defined case-ness in 62 patients. Long QTc categories, drawn from epidemiological reports, encompassed 440 to 469 (borderline), 470 to 499 (moderate), and 500+ milliseconds (severe). Data collection included electrocardiograms, demographic characteristics, contributors to long QTc, and interventions-plus-outcomes (defined by resolution of long QTc). Of 62 patients, 21 had 39 long QTc episodes-a 4-year case prevalence of 34%, and an annual episode incidence of 15.7 per 100. Contributing factors identified in 36 of 39 episodes consisted of medication management (n = 19), illicit drug use (n = 11), and other factors (n = 6). Long QTc reverted to normal in 38 of 39 episodes. Of 21 patients, 12 (57%) experienced one or two recurrences. Methadone maintenance treatment physicians normalized most episodes as outpatients, often in collaboration with patients' primary care physicians. One fifth of episodes required hospitalization and other specialty care. Lack of timely QTc normalization may have accounted for one sudden death.

Effect of Antidepressant Switching vs Augmentation on Remission Among Patients With Major Depressive Disorder Unresponsive to Antidepressant Treatment: The VAST-D Randomized Clinical Trial.

IMPORTANCE: Less than one-third of patients with major depressive disorder (MDD) achieve remission with their first antidepressant. OBJECTIVE: To determine the relative effectiveness and safety of 3 common alternate treatments for MDD. DESIGN, SETTING, AND PARTICIPANTS: From December 2012 to May 2015, 1522 patients at 35 US Veterans Health Administration medical centers who were diagnosed with nonpsychotic MDD, unresponsive to at least 1 antidepressant course meeting minimal standards for treatment dose and duration, participated in the study. Patients were randomly assigned (1:1:1) to 1 of 3 treatments and evaluated for up to 36 weeks. INTERVENTIONS: Switch to a different antidepressant, bupropion (switch group, n = 511); augment current treatment with bupropion (augment-bupropion group, n = 506); or augment with an atypical antipsychotic, aripiprazole (augment-aripiprazole group, n = 505) for 12 weeks (acute treatment phase) and up to 36 weeks for longer-term follow-up (continuation phase). MAIN OUTCOMES AND MEASURES: The primary outcome was remission during the acute treatment phase (16-item Quick Inventory of Depressive Symptomatology-Clinician Rated [QIDS-C16] score ≤5 at 2 consecutive visits). Secondary outcomes included response (≥50% reduction in QIDS-C16 score or improvement on the Clinical Global Impression Improvement scale), relapse, and adverse effects. RESULTS: Among 1522 randomized patients (mean age, 54.4 years; men, 1296 [85.2%]), 1137 (74.7%) completed the acute treatment phase. Remission rates at 12 weeks were 22.3% (n = 114) for the switch group, 26.9% (n = 136)for the augment-bupropion group, and 28.9% (n = 146) for the augment-aripiprazole group. The augment-aripiprazole group exceeded the switch group in remission (relative risk [RR], 1.30 [95% CI, 1.05-1.60]; P = .02), but other remission comparisons were not significant. Response was greater for the augment-aripiprazole group (74.3%) than for either the switch group (62.4%; RR, 1.19 [95% CI, 1.09-1.29]) or the augment-bupropion group (65.6%; RR, 1.13 [95% CI, 1.04-1.23]). No significant treatment differences were observed for relapse. Anxiety was more frequent in the 2 bupropion groups (24.3% in the switch group [n = 124] vs 16.6% in the augment-aripiprazole group [n = 84]; and 22.5% in augment-bupropion group [n = 114]). Adverse effects more frequent in the augment-aripiprazole group included somnolence, akathisia, and weight gain. CONCLUSIONS AND RELEVANCE: Among a predominantly male population with major depressive disorder unresponsive to antidepressant treatment, augmentation with aripiprazole resulted in a statistically significant but only modestly increased likelihood of remission during 12 weeks of treatment compared with switching to bupropion monotherapy. Given the small effect size and adverse effects associated with aripiprazole, further analysis including cost-effectiveness is needed to understand the net utility of this approach. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01421342.

Methadone maintenance dose/weight ratio, long QTc, and EKG screening.

BACKGROUND AND OBJECTIVES: Electrocardiogram (EKG) monitoring during methadone maintenance treatment (MMT) has been recommended to prevent potentially fatal prolonged computed QT intervals (QTc). However, risk indicators for obtaining EKGs do not exist. This study assessed 23 variables that might help identify prolonged QTc during MMT. METHODS: EKGs concurrent with methadone serum levels were obtained from 69 veterans during a 5-year study, encompassing 302.8 person-years. Two cardiologists hand-measured QT intervals, selecting each patient's longest QTc. QTc categories included: normal duration <440 ms; borderline duration of 440-469 ms; and abnormal duration ≥470 ms. QTc's were compared with seven methadone parameters and 16 bio-psycho-social variables using two QTc cut-offs (440 and 470 ms). RESULTS: Among the 69 patients, 19 had normal QTc's, 28 had borderline QTc's, and 22 had abnormal QTc's. Methadone dose/weight was moderately correlated with QTc, and independently associated with longer QTc at both 440 and 470 cut-offs. DISCUSSION AND CONCLUSION: Dose/weight ≥.49 is useful for screening EKGs for QTc's ≥440 cut-off. Dose/weight ≥.65 produces high-yield abnormal QTc's ≥470 cut-off. SCIENTIFIC SIGNIFICANCE: Methadone dose/weight provides moderately reliable thresholds for making routine screening decisions and urgent clinical decisions to obtain an EKG for prolonged QTc. (Am J Addict 2016;25:499-507).

How Do Clinicians Prefer Cultural Competence Training? Findings from the DSM-5 Cultural Formulation Interview Field Trial.

OBJECTIVE: This study's objective is to analyze training methods clinicians reported as most and least helpful during the DSM-5 Cultural Formulation Interview field trial, reasons why, and associations between demographic characteristics and method preferences. METHOD: The authors used mixed methods to analyze interviews from 75 clinicians in five continents on their training preferences after a standardized training session and clinicians' first administration of the Cultural Formulation Interview. Content analysis identified most and least helpful educational methods by reason. Bivariate and logistic regression analysis compared clinician characteristics to method preferences. RESULTS: Most frequently, clinicians named case-based behavioral simulations as "most helpful" and video as "least helpful" training methods. Bivariate and logistic regression models, first unadjusted and then clustered by country, found that each additional year of a clinician's age was associated with a preference for behavioral simulations: OR = 1.05 (95 % CI: 1.01-1.10; p = 0.025). CONCLUSIONS: Most clinicians preferred active behavioral simulations in cultural competence training, and this effect was most pronounced among older clinicians. Effective training may be best accomplished through a combination of reviewing written guidelines, video demonstration, and behavioral simulations. Future work can examine the impact of clinician training satisfaction on patient symptoms and quality of life.

Are there racial/ethnic disparities in VA PTSD treatment retention?

BACKGROUND: Chronic posttraumatic stress disorder (PTSD) can result in significant social and physical impairments. Despite the Department of Veterans Affairs' (VA) expansion of mental health services into primary care clinics to reach larger numbers of Veterans with PTSD, many do not receive sufficient treatment to clinically benefit. This study explored whether the odds of premature mental health treatment termination varies by patient race/ethnicity and, if so, whether such variation is associated with differential access to services or beliefs about mental health treatments. METHODS: Prospective national cohort study of VA patients who were recently diagnosed with PTSD (n = 6,788). Self-administered surveys and electronic VA databases were utilized to examine mental health treatment retention across racial/ethnic groups in the 6 months following the PTSD diagnosis controlling for treatment need, access factors, age, gender, treatment beliefs, and facility factors. RESULTS: African American and Latino Veterans were less likely to receive a minimal trial of pharmacotherapy and African American Veterans were less likely to receive a minimal trial of any treatment in the 6 months after being diagnosed with PTSD. Controlling for beliefs about mental health treatments diminished the lower odds of pharmacotherapy retention among Latino but not African American Veterans. Access factors did not contribute to treatment retention disparities. CONCLUSIONS: Even in safety-net healthcare systems like VA, racial and ethnic disparities in mental health treatment occur. To improve treatment equity, clinicians may need to more directly address patients' treatment beliefs. More understanding is needed to address the treatment disparity for African American Veterans.

Suicidal ideation and suicide attempts in five groups with different severities of gambling: Findings from the National Epidemiologic Survey on Alcohol and Related Conditions.

BACKGROUND AND OBJECTIVES: Problem and pathological gamblers show high rates of suicidal behavior. However, previous research of suicide among this population has been inconsistent. Discrepancies may stem from methodological issues, including variable use of suicide nomenclature and selection bias in study samples. Furthermore, earlier research has rarely examined gambling severity aside from problem or pathological categories. This study utilized subgroups derived from a nationally representative data set, examining different characteristics of suicidal behavior and several gambling levels, including subclinical groups. METHODS: Participants included 13,578 individuals who participated in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) and provided information on gambling behavior, lifetime suicidal ideation, and/or lifetime suicide attempts. Five gambling groups were derived using DSM-IV criteria for pathological gambling; non-gambling, low-risk gambling, at-risk gambling, problem gambling, and pathological gambling. RESULTS: Problem gambling was associated with suicidal ideation [adjusted odds ratio (AOR) = 1.64, 95% confidence interval (CI) = 1.19-2.26] and suicide attempts [(AOR) = 2.42, 95% (CI) = 1.60-3.67] after adjustment for sociodemographic variables. Pathological gambling was associated with suicidal ideation [(AOR) = 2.86, 95% (CI) = 1.98-4.11] and suicide attempts [(AOR) = 2.77, 95% (CI) = 1.72-4.47) after adjustment for sociodemographic variables. DISCUSSION, CONCLUSIONS, AND SCIENTIFIC SIGNIFICANCE: Our results from this population sample reinforce increased rates of suicidal behavior amongst smaller, clinical samples of problem and pathological gamblers. Education for providers about gambling is recommended, including screening for gambling-related symptoms such as suicidal behavior.

Housing First/HUD-VASH: Importance, Flaws, and Potential for Transformation: Response to Commentary.

This paper consists of responses to issues raised in the accompanying Commentary. Our response is organized under three topics: (1) reasons regarding the importance of issues, (2) the need for a comprehensive framework in housing placement, and (3) conceptualization and scientific design (with details on contemporary methods for investigating unanticipated consequences when randomization is no longer feasible). Recurrences to substance use disorder in the American Society of Addiction Medicine (ASAM) housing placement condition are noted within hours or days, with rapid implementation of planned contingencies, and avoidance of enabling. Recurrences in the Housing First/HUD-VASH (HF/H-V) condition escape notice for weeks to months, and continued use is accepted as a core principle of the program. HF/H-V contingencies occur later for major disruptions, leading to discharge. For patients recruited from our clinic, HF/H-V performed poorly when compared to a long-accepted standard of care, the ASAM placement criteria.

Internalizing disorder in adopted versus non-adopted adults: a NESARC based study.

The objective of the study consisted of comparing lifetime prevalence rates and odds ratios of anxiety, mood, and psychotic disorders in adopted-versus-non-adopted people in a nationally representative sample. The data were drawn from the National Epidemiological Survey on Alcohol and Related Conditions (NESARC). The main outcome measure was the prevalence of lifetime internalizing psychiatric disorders in adopted (n=378) versus non-adopted (n=42,503) individuals. Adoptees and non-adoptees were compared to estimate the odds of lifetime internalizing disorders using logistic regression analyses. Adoptees had higher prevalence rates of several lifetime mood and anxiety disorders compared with non-adoptees, with a 1.61-fold increase (95% CI 1.29-2.02) in the odds of any mood disorder and a 1.49-fold increase (95% CI 1.18-1.89) in the odds of any anxiety disorder compared with non-adoptees. Regarding specific mood and anxiety disorders, adoptees had increased odds of major depressive disorder, bipolar I disorder, panic disorder without agoraphobia, specific phobia, and generalized anxiety disorder. Disorders not differing between adoptees and non-adoptees included dysthymia, bipolar II disorder, panic disorder with agoraphobia, social phobia, and psychotic disorder. One adoption-specific risk factor was associated with lifetime mood disorder (i.e., Asian/Pacific Island). In conclusion, adoptees in a large sample from the general population had higher rates of mood and anxiety disorders compared to non-adoptees.

Actigraphy in post traumatic stress disorder.

UNLABELLED: Patients with posttraumatic stress disorder (PTSD) frequently complain of sleep disturbances such as insomnia and nightmares. Evaluation of sleep disturbances is often difficult due to the subjective nature of the complaints. Polysomnography (PSG) and other sleep studies are generally not indicated in the evaluation of insomnia or nightmares associated with PTSD. Actigraphy, (electronic activity monitoring) has been used in research to evaluate sleep disturbances in patients with PTSD. We reviewed the literature on the use of actigraphy in evaluation of sleep problems in patients with PTSD. METHODS: A literature search for articles on the topic was conducted on PubMed using the search algorithm (actigraphy[Title/Abstract] OR actigraphic[Title/Abstract]) AND PTSD[Title/Abstract]. Out of 11 search results, 9 studies in which application of actigraphy had relevance to the primary objective and outcome in PTSD patients with sleep problems were selected for review. We also handpicked one additional article from personal communication with our colleagues who have done some of these studies. CONCLUSION: Actigraphy has been used to evaluate circadian rhythm sleep disorders. Use of actigraphy in psychiatry clinics is uncommon. There is no data to support that there are specific actigraphic sleep related findings in PTSD patients. However, it can be a useful tool to complement the use of sleep diaries when assessing sleep and wake patterns in patients with PTSD.

Residential placement for veterans with addiction: American Society of Addiction Medicine criteria vs. a veterans homeless program.

The goal of this study was to compare placements of patients with addiction undertaken by a) a unidimensional, protocol-driven, independent "permanent" housing "wet" program versus b) a multidimensional, patient-individualized, contingency-based housing approach. The sample consisted of eight veterans in a single team's panel admitted to a housing program and eight matched veterans on the verge of homelessness placed by the team according to the American Society of Addiction Medicine (ASAM) criteria. The two groups (matched for sex, race-ethnicity, and age [SD, 5 years]) were similar on demography, substance disorder, and psychiatric comorbidity. Measures consisted of a) description of the placements, b) 12-month postplacement outcomes using a 12-item scale, and c) a Drug Abuse Research Project-based 10-item scale to assess recovery processes at two 6-month preplacement and two 6-month postplacement intervals. The veterans in the housing program escalated drinking and/or drug use; all were readdicted by the end of 12 months after placement. In the ASAM-criteria group, five of the eight patients had brief slips lasting 2 days or less, but none were readdicted at 12 months. The housing program group experienced five nontrivial outcomes: three imprisonments for felonies, one life-threatening medical complication, and one death. In conclusion, the findings support close monitoring and relevant contingencies using the ASAM criteria in the treatment of substance use disorder.

Cultural psychiatry in the French-speaking world.

For the last five centuries, France's international influence has been constant. This has been particularly evident in the areas of general culture, history and science. In psychiatry, the role of Pinel during the French Revolution, and the discovery of the first psychotropic agent, chlorpromazine, by Delay and Deniker are two outstanding historical facts. This chapter examines the contributions of French social scientists in the understanding of the sequelae of colonial exploitation, racism and political oppression. The establishment of a multi-ethnic society in France and Francophile regions of the world has led to the gradual creation of a cultural psychiatry rich in terminological influences, clinical understanding, training programs and research. Closer connections between French psychiatric thought and Anglophile psychiatry is likely to produce beneficial effects.

Posttraumatic stress disorder and its comorbidities among American Indian veterans.

Goal consists of describing the demographic and comorbid characteristics associated with Posttraumatic Stress Disorder (PTSD) among American Indian veterans with any lifetime Axis 1 disorder. Sample included 252 American Indian veterans, obtained from a community sample of 557, using targeted sampling designed to provide a representative sample, structured to include equal numbers of rural and urban veterans and a twofold over sample of women. Data collection involved lifetime diagnoses based on the Diagnostic Interview Schedule/Quick Version/DSM-III-R, demographic characteristics, and combat exposure. Findings Bivariate comparisons showed positive relationships of PTSD with combat exposure, mood disorder and anxiety disorders (excluding PTSD), but a negative relationship with substance use disorder. Binary logistic regression analyses showed an independent association of PTSD with mood and anxiety disorders as well as combat exposure.