Psychological distress and line-of-duty head injuries in firefighters.

BACKGROUND: Head injuries are common injury in the fire service; however, very little data exist on the risks this may pose to the development of post-traumatic stress disorder (PTSD) and depression in this high-risk population. AIMS: Our study aimed to compare levels of PTSD and depression symptoms in firefighters with a line-of-duty head injury, non-line-of-duty head injury and no head injury. METHODS: In this cross-sectional study, we assessed current PTSD and depression symptoms as well as retrospective head injuries. RESULTS: Seventy-six per cent of the total sample reported at least one head injury in their lifetime. Depression symptoms were significantly more severe among firefighters with a line-of-duty head injury compared to those with no head injury, but not compared to those who sustained a non-line-of-duty head injury. Depression symptoms did not differ between firefighters with a non-line-of-duty head injury and those with no head injury. PTSD symptoms were significantly more severe among firefighters with a line-of-duty head injury compared to both firefighters with no head injury and those with a non-line-of-duty head injury. CONCLUSIONS: We found that firefighters who reported at least one line-of-duty head injury had significantly higher levels of PTSD and depression symptoms than firefighters who reported no head injuries. Our findings also suggest head injuries sustained outside of fire service could have less of an impact on the firefighter's PTSD symptom severity than head injuries that occur as a direct result of their job.

Alcohol use and mental health symptoms in female firefighter recruits.

BACKGROUND: Limited research suggests that female firefighters report problem drinking at higher rates than the general population. AIMS: To identify longitudinal drinking patterns in female firefighters, make comparisons to male firefighters and examine problem drinking in relation to post-traumatic stress disorder (PTSD) and depression. METHODS: Study participants included 33 female and 289 male firefighter recruits, who were assessed over their first 3 years of fire service. RESULTS: Female firefighters consumed increasing numbers of drinks per week, with a median of 0.90 drinks per week at baseline, and 1.27 drinks in year 3. Female firefighters reported binge drinking at high rates, with nearly half binging at least once per year across all time points (44-74%). The percentage that reported binge drinking three or more times per month doubled over the course of the study (from 9% to 18%). Overall, males reported higher rates of binge drinking and a greater number of drinks per week; however, binge drinking rates among females increased over time and became comparable to rates of binge drinking among males. A greater percentage of female than male firefighters met the criteria for problem drinking by year 1. Problem drinking was associated with screening positive for PTSD at year 1 and depression at year 2, but not with occupational injury. CONCLUSIONS: Over time, female firefighters reported increasing amounts of drinking, more frequent binge drinking and more negative consequences from drinking. These findings along with existing literature indicate female firefighters change their drinking in the direction of their male counterparts.

Towards global consensus on core outcomes for hidradenitis suppurativa research: an update from the HISTORIC consensus meetings I and II.

BACKGROUND: A core outcomes set (COS) is an agreed minimum set of outcomes that should be measured and reported in all clinical trials for a specific condition. Hidradenitis suppurativa (HS) has no agreed-upon COS. A central aspect in the COS development process is to identify a set of candidate outcome domains from a long list of items. Our long list had been developed from patient interviews, a systematic review of the literature and a healthcare professional survey, and initial votes had been cast in two e-Delphi surveys. In this manuscript, we describe two in-person consensus meetings of Delphi participants designed to ensure an inclusive approach to generation of domains from related items. OBJECTIVES: To consider which items from a long list of candidate items to exclude and which to cluster into outcome domains. METHODS: The study used an international and multistakeholder approach, involving patients, dermatologists, surgeons, the pharmaceutical industry and medical regulators. The study format was a combination of formal presentations, small group work based on nominal group theory and a subsequent online confirmation survey. RESULTS: Forty-one individuals from 13 countries and four continents participated. Nine items were excluded and there was consensus to propose seven domains: disease course, physical signs, HS-specific quality of life, satisfaction, symptoms, pain and global assessments. CONCLUSIONS: The HISTORIC consensus meetings I and II will be followed by further e-Delphi rounds to finalize the core domain set, building on the work of the in-person consensus meetings.

Naltrexone and cue exposure with coping and communication skills training for alcoholics: treatment process and 1-year outcomes.

BACKGROUND: Promising treatments for alcoholics include naltrexone (NTX), cue exposure combined with urge-specific coping skills training (CET), and communication skills training (CST). This study investigated the effects of combining these elements as treatment adjuncts. METHODS: A 2 x 2 design investigated the effects of CET combined with CST, as compared with an education and relaxation control treatment, during a 2-week partial hospital program (n = 165) followed by 12 weeks of NTX (50 mg/day) or placebo during aftercare (n = 128). Drinking outcomes were assessed at 3, 6, and 12 months after discharge from the partial hospital. Process measures included urge, self-efficacy (confidence about staying abstinent in risky situations), and self-reported coping skills. Medically eligible alcohol-dependent patients were recruited. RESULTS: Among those compliant with medication on at least 70% of days, those who received NTX had significantly fewer heavy drinking days and fewer drinks on days that they drank than those receiving placebo during the medication phase but not during the subsequent 9 months. CET/CST-condition patients were significantly less likely to report a relapse day and reported fewer heavy drinking days at the 6- and 12-month follow-ups than patients in the control treatment. Interactions of medication with behavioral treatments were not significant. Process measures showed that NTX resulted in lower weekly urge ratings, and those in CET/CST used more of the prescribed coping skills after treatment, reported fewer cue-elicited urges, and reported more self-efficacy in a posttest role-play test. Drinking reductions at 3, 6, and 12 months correlated with more use of coping skills, lower urge, and higher self-efficacy. CONCLUSIONS: The results suggest the probable value of keeping alcoholics on NTX for longer periods of time and the importance of increasing compliance with NTX. They also support the earlier promising effects of CET and CST as adjuncts to treatment programs for alcoholics by maintaining treatment gains over at least a year. The value of the urge-specific and general coping skills and of self-efficacy and urge constructs was demonstrated in their association with drinking outcomes.

Cue exposure with coping skills training and communication skills training for alcohol dependence: 6- and 12-month outcomes.

AIMS: Cue exposure treatment (CET) has shown promise in preliminary studies with alcoholics, and Communication Skills Training (CST) has been found beneficial, especially in intensive treatment programs. The aim of the present study was to investigate the effects of CET and CST in a larger controlled study when both were added to intensive treatment programs. DESIGN AND INTERVENTIONS: A 2 x 2 design investigated the effects of CET with urge coping skills training compared to a meditation-relaxation control, and CST compared to an education control when all were added to intensive treatment programs for alcoholics. SETTING: The sites were the inpatient or partial hospital substance abuse treatment programs at a private psychiatric hospital, a state-funded residential facility and a VA medical center. PARTICIPANTS: Patients diagnosed with alcohol dependence without active psychosis were eligible. MEASUREMENTS: Participants were assessed for quantity and frequency of drinking, alcohol cue-reactivity, responses to high risk simulations and urge specific coping skills. FINDINGS: Of 100 treated patients, 86% provided 6-month and 84% provided 12-month follow-up data. Patients who received either CET or CST had fewer heavy drinking days in the first 6 months than control patients. In the second 6 months, CET continued to result in fewer heavy drinking days among lapsers and interacted with CST to decrease quantity of alcohol consumed. CST resulted in fewer alcohol-related problems reported at 12 months. CET resulted in greater reductions in urge to drink in a measure of simulated high-risk situations. CET also resulted in greater reports of use of coping strategies during the follow-up, and many of the urge-specific strategies taught in CET were associated with reduced drinking. CONCLUSIONS: Both CET and CST continue to show promise as elements of comprehensive alcohol treatment programs. Limitations and directions for future research are discussed.

Smoking and drinking among alcoholics in treatment: cross-sectional and longitudinal relationships.

OBJECTIVE: The relationship between tobacco dependence and alcohol dependence has received considerable scrutiny in the past few years. The present study of alcoholics in treatment for alcoholism extended previous work by investigating the cross-sectional and longitudinal relationships between drinking and smoking variables. METHOD: Male and female alcoholics (N = 116) completed a standard assessment of smoking and drinking pretreatment followed by a laboratory assessment of reactivity to alcohol cues. Participants' drinking and smoking were evaluated again 6 months following treatment. RESULTS: (1) Pretreatment tobacco dependence, pretreatment alcohol dependence, urge to smoke and urge to drink were positively correlated; (2) smoking rates and drinking rates were not correlated either before or following treatment; (3) pretreatment smoking history did not predict posttreatment drinking; (4) the rate of smoking declined following treatment for alcoholism for 45% of the smoking patients who completed a 6-month follow-up, independent of relapse status; and (5) relapsers who smoked more heavily also drank less frequently during follow up. CONCLUSIONS: Consistent but modest cross-sectional relationships between drinking and smoking variables before alcohol treatment decrease after treatment for alcohol dependence. A spontaneous improvement in smoking rate occurs in many (45%), particularly among those who smoked more heavily pretreatment and thus benefit most by the reduction. Directions for future research are discussed.

Naltrexone's effect on cue-elicited craving among alcoholics in treatment.

BACKGROUND: Advancing knowledge of biobehavioral effects of interventions can result in improved treatments. Thus, a standardized laboratory cue reactivity assessment has been developed and validated to assess the cognitive and psychophysiological responses to a simulated high-risk situation: alcohol cues. The present study investigates the effects of a pharmacotherapy (naltrexone) on a laboratory-based, cue-elicited urge to drink among abstinent alcoholics in treatment. METHODS: Alcohol-dependent subjects were randomized to 12 weeks of naltrexone or placebo after completing a partial hospital program. After approximately 1 week on medication, all received cue reactivity assessment. RESULTS: Significantly fewer patients taking naltrexone reported any urge to drink during alcohol exposure than did those on placebo. Those with any urges reported no decrement in level of the urges. Mean arterial pressure decreased significantly for those on placebo, but not for those on naltrexone, whereas cue-elicited decreases in heart rate were not affected by the medication. CONCLUSIONS: The results have implications for models of relapse and naltrexone's effects. Cue reactivity methodology has utility for investigating hypothesized mediators of therapeutic effects of pharmacotherapies as well as behavioral treatments.

Alcohol cue reactivity and private self-consciousness among male alcoholics.

Recent alcohol cue exposure studies have noted that not all alcoholics demonstrate increased reactivity when presented with alcohol-related cues. This study examined the relationship of private self-consciousness (PSC) to subjective, self-report measures of reactivity and measures of negative mood states that involve a focus on internal processes. These subjective measures of reactivity were contrasted with salivary reactivity, an objective measure of reactivity which does not require individual self-report or awareness. A cue reactivity assessment was administered to 47 men meeting DSM-III-R criteria for a diagnosis of alcohol dependence. Our hypothesis, that PSC would predict urge reactivity status and greater levels of negative mood states, was supported. Urge reactors were more likely to be high in PSC, while the proportions of salivary reactors and nonreactors were not significantly different between the high and low PSC groups. Although regression analyses indicated that PSC did not significantly predict urge to drink alcohol, it did predict angry/frustrated mood and sad/depressed mood at the first alcohol trial. These results suggest that individuals high in PSC may benefit more from cue exposure-based treatment, as they are more likely to be urge reactors and to evidence negative mood reactivity. Low PSC individuals may be at higher risk for relapse given they are less able to recognize internal reactions signaling the presence of a high-risk alcohol use situation, and therefore less likely to mobilize coping responses.

Effects of alcohol cues on smoking urges and topography among alcoholic men.

Although the prevalence of smoking among alcoholics ranges up to 97%, little is known about mechanisms underlying the co-occurrence of smoking and alcohol use, or the role tobacco may play in alcohol treatment recovery. Adult male alcoholics in treatment (n = 30) were randomly assigned to visual and olfactory exposure either to alcohol cues or to control cues, and then were allowed to smoke while continuing visual exposure to the same cues. Exposure to alcohol cues resulted in significantly greater self-reported urge to drink and urge to smoke but had no significant effect on the topography of smoking behavior. When variance due to urge to smoke was controlled, greater urge to drink correlated negatively with number of cigarette puffs. The results provide some support for a priming hypothesis of tobacco's role on alcoholism recovery. Clinical and theoretical implications are discussed.

Exposure to negative emotional cues and alcohol cue reactivity with alcoholics: a preliminary investigation.

Fifty-one male and female inpatient alcoholics received cue exposure treatment involving in vivo exposure to alcohol cues and imaginal exposure to individualized high-risk drinking situations involving negative emotional cues. At post-test, self-report measures of urge to drink alcohol and negative emotional states were obtained during an alcohol cue reactivity assessment. Contrary to our hypothesis, greater exposure to negative emotional cues during treatment was associated with greater urge and negative emotional responses at post-test. In addition, greater duration of exposure to negative emotional cues predicted greater attention to alcohol-related stimuli and thoughts about drinking during the post-test. Implications for future research in this area include extending the duration of exposure to negative emotional cues in order to establish the optimal exposure durations within which a majority of individuals achieve clinically significant reductions in their urge to drink alcohol.

Interventions with retailers to reduce cigarette sales to minors: a randomised controlled trial.

We aimed to determine the relative effectiveness of an education intervention and a threat-of-enforcement intervention in reducing sales of cigarettes to under-age youth by randomly allocating 300 retailers in a nonmetropolitan region of New South Wales to: a control group with no intervention; a minimal-intervention group, which received an educational letter; and a maximal-intervention group, which received a threat of enforcement followed by a visit from a public health officer. Retailers were checked for compliance at pretest and post-test, six months apart, by twelve 18-year-olds who were judged by independent raters to look younger. The retailers were surveyed by telephone at both times for knowledge, attitudes and self-reported sales practices. Neither intervention achieved significant improvements for the two key behavioural outcomes: requiring proof of age and display of a warning sign. Neither was there an intervention effect on knowledge about the law. The greatest improvement in the proportion of retailers who believed that the legal age should be 18 or over was in the minimal-intervention group, and both intervention groups were less likely than the control group at post-test to think that it was acceptable to sell to a person who was nearly 18. There was poor overall compliance with the revised legislation at pre-test. The finding of a pretest-to-post-test improvement but no differential intervention effect highlights the methodological difficulties of such research. The interventions may, however, have been partly successful in modifying the attitudes of retailers.

An investigation of self-efficacy, partner support and daily stresses as predictors of relapse to smoking in self-quitters.

Six hundred and thirty smokers who intended to quit smoking themselves completed pre-cessation measures of self-efficacy, partner support, daily stresses and demographics. Subjects were contacted at 2, 7, 14, 30, 90 and 180 days post-cessation to determine smoking status and to re-administer the measures at 7, 14 and 30 days post-cessation. A series of logistic regression examined which prospective factors best predicted relapse between 0-2 days, 3-7 days, 8-14 days, 15-30 days, 31-90 days and 91-180 days. Relapse was predicted by different variables at different times; however, self-efficacy was a consistent predictor of relapse over time.

Interrelationship of smoking and alcohol dependence, use and urges to use.

OBJECTIVE: The relationship between tobacco dependence and alcohol dependence has received little empirical scrutiny. The present study of alcoholics in treatment for alcoholism investigated pretreatment tobacco and alcohol history and dependence, as well as subjective responsivity to alcohol cues. METHOD: Eighty-three male alcoholics underwent a questionnaire assessment of smoking and drinking pretreatment followed by a laboratory assessment of reactivity to alcohol cues. RESULTS: The analyses demonstrate that (1) pretreatment tobacco dependence and pretreatment alcohol dependence are related, (2) alcohol dependence predicts urges to smoke during alcohol treatment, (3) exposure to alcohol cues results in increased urge to smoke, (4) smoking when ill predicts urge to drink during alcohol cue exposure and (5) urge to smoke is positively correlated with urge to drink. CONCLUSIONS: These data, collected in a population of alcoholics not currently receiving smoking interventions, indicate that smoking may be a factor to address during alcohol treatment. The clinical importance of these data is discussed.

The effects of cue exposure on reaction time in male alcoholics.

The present study investigates reaction time (RT) as a measure of attentional deficits produced during alcohol cue exposure. Twenty-four male alcoholic patients responded to a series of computer-generated tones as rapidly as possible during baseline and again during either an alcohol cue exposure period or exposure to a control beverage (water). Patients required increased time to respond to the tones when exposed to alcohol cues. No such increase in RT was found during exposure to a control beverage. In addition, RT was significantly correlated with self-reported urge to drink. These data provide initial validation for the use of RT as an objective measure of cue reactivity. Both theoretical and clinical implications for the use of RT as a measure of the effects of cue exposure are discussed.

Alcohol cue reactivity and mood induction in male and female alcoholics.

The purpose of this study was twofold: to investigate gender differences in alcohol cue reactivity, and to study the effect of individualized mood induction on cue reactivity. Male (n = 38) and female (n = 19) alcoholics were exposed to an alcoholic beverage before and after mood induction to assess their reactivity to the beverage cues. The mood induction was based on a situation the subject had identified as being high risk for relapse. Subjects showed urge and salivary reactivity in response to alcohol beverage cues prior to mood induction, and the induction of mood enhanced urge reactivity in both men and women. Analyses with alcohol urge reactors (subjects that demonstrate an increased urge to drink alcohol in response to an alcoholic beverage cue) suggested that women show more urge reactivity in response to negative moods than do men. No gender differences were seen in reactivity to beverage cues alone. These results identify an important gender difference in the effect of negative moods on cue reactivity and suggest that negative mood situations may place women at a higher risk for relapse than men.

Smoking cessation among self-quitters.

We examined cessation among 630 smokers who quit abruptly on their own. Continuous, complete abstinence rates were 33% at 2 days, 24% at 7 days, 22% at 14 days, 19% at 1 month, 11% at 3 months, 8% at 6 months postcessation, and 3% at 6 months with biochemical verification. Slipping (smoking an average of less than 1 cigarette/day) was common (9% to 15% of subjects) and was a strong predictor of relapse; however, 23% of long-term abstainers slipped at some point. These results challenge beliefs that most smokers can initially stop smoking and that most relapse occurs later on postcessation.

Caffeine self-administration, withdrawal, and adverse effects among coffee drinkers.

Twenty-two coffee drinkers (three to seven cups per day) underwent repeated double-blind trials to test for caffeine self-administration, withdrawal, and adverse effects. Each trial consisted first of a randomized crossover period of 1 day of decaffeinated coffee and 1 day of caffeinated coffee (100 mg) to assess withdrawal and adverse effects of caffeine. Next, subjects were given 2 days of concurrent access to the two coffees. The relative use of the two coffees was used to assess caffeine self-administration. Reliable caffeine self-administration occurred in three of 10 subjects in study 1 and seven of 12 subjects in study 2. Withdrawal symptoms were headaches, drowsiness, and fatigue. The major adverse effect from self-administration was tremulousness. The occurrence of headaches on substitution of decaffeinated coffee prospectively predicted subsequent self-administration of caffeine. These results indicate that some coffee drinkers exhibit signs of a caffeine dependence, ie, they self-administer coffee for the effects of caffeine, have withdrawal symptoms on cessation, and experience adverse effects.

Smoking history, instructions and the effects of nicotine: two pilot studies.

In Study 1, ten never-smokers, ten ex-smokers and nine current smokers received nicotine (2 mg) and placebo gum hourly for 4 hours on 2 consecutive days in a randomized, double-blind, cross-over protocol. Dysphoria from nicotine was greatest in never-smokers, intermediate in ex-smokers, and least in current smokers (p less than 0.05). On the third day, subjects were given concurrent access to the same gums and told to chew ad lib. Across all subjects, nicotine was an aversive stimulus (i.e., self-administered less than placebo). Nicotine was avoided most in never-smokers, intermediate in ex-smokers and least in current smokers (p less than 0.05). Study 2 used a similar protocol and compared the nine current smokers in Study 1 who were not told they would receive nicotine with eight informed smokers, i.e., smokers told they would receive nicotine. Although nicotine appeared to be a reinforcer more often in the informed smokers than in the uniformed smokers (63% vs. 22%), this result was not statistically significant. Our results suggest 1) past drug history can influence the stimulus effects of nicotine and 2) the effects of instructions on the response to nicotine may be less in experimental settings than in therapeutic settings.

Effect of instructions and nicotine on smoking cessation, withdrawal symptoms and self-administration of nicotine gum.

Seventy-seven smokers quit smoking and were randomly assigned to a 3 x 2 design contrasting instructions (told received nicotine gum versus told received placebo gum versus not told which gum received) and receipt of nicotine (received nicotine gum versus received placebo gum). Both being told one received nicotine and actual receipt of nicotine increased the number of days abstinent and decreased the number of cigarettes smoked (P less than 0.05). Receipt of nicotine but not instructions appeared to influence withdrawal (P = 0.06). Instructions but not receipt of nicotine appeared to influence craving (P = 0.08), gum self-administration (P = 0.06) and reported helpfulness of the gum (P = 0.02). Neither nicotine nor instructions influenced side-effects. Instructions and nicotine interacted in several ways. For example, nicotine appeared to increase abstinence in the blind and told placebo conditions more than in the told nicotine condition (P less than 0.05). Our results suggest the effects of instructions and nicotine 1) are not mutually exclusive, 2) vary across dependent variables and 3) can interact such that instructions modify the therapeutic and subjective effects of nicotine.