Risk of death for veterans on release from prison.

We sought to determine, among veterans released from Washington state prisons from 1999 through 2003, the risk of death from all causes, whether those veterans have faced a higher risk of death than have nonveterans, and whether having VA benefits decreased the risk of death. We linked data from a retrospective cohort study to data from the Veterans Benefit Administration. Mortality rates were compared between veteran and nonveteran former inmates. The crude rate of veteran mortality was 1,195 per 100,000 person-years, significantly higher than that of nonveterans (p < .001), but adjustment for demographic factors demonstrated no significant increased risk. VA benefits were associated with a reduced risk for all-cause deaths (hazard ratio, .376; 95% confidence interval, 0.18-0.79). Veterans share the heightened risk of death after release from prison faced by all released inmates and should be included in efforts to reduce the risks associated with transitioning from prison to the community. VA benefits appear to offer a protective effect, particularly against medical deaths.

Inhibition of the P50 cerebral evoked response to repeated auditory stimuli: results from the Consortium on Genetics of Schizophrenia.

Inhibition of the P50 evoked electroencephalographic response to the second of paired auditory stimuli has been frequently examined as a neurophysiological deficit in schizophrenia. The Consortium on the Genetics of Schizophrenia (COGS), a 7-site study funded by the National Institute of Mental Health, examined this endophenotype in recordings from 181 probands with schizophrenia, 429 of their first degree relatives, and 333 community comparison control subjects. Most probands were treated with second generation antipsychotic medications. Highly significant differences in P50 inhibition, measured as either the ratio of amplitudes or their difference in response to the two stimuli, were found between the probands and the community comparison sample. There were no differences between the COGS sites for these findings. For the ratio parameter, an admixture analysis found that nearly 40% of the relatives demonstrated deficiencies in P50 inhibition that are comparable to the deficit found in the probands. These results indicate that P50 auditory evoked potentials can be recorded across multiple sites and reliably demonstrate a physiological abnormality in schizophrenia. The appearance of the physiological abnormality in a substantial proportion of clinically unaffected first degree relatives is consistent with the hypothesis that deficits in cerebral inhibition are a familial neurobiological risk factor for the illness.

Neuropsychological test performance in soldiers with blast-related mild TBI.

This exploratory study was conducted to increase understanding of neuropsychological test performance in those with blast-related mild traumatic brain injury (mTBI). The two variables of interest for their impact on test performance were presence of mTBI symptoms and history of posttraumatic stress disorder (PTSD). Forty-five soldiers postblast mTBI, 27 with enduring mTBI symptoms and 18 without, completed a series of neuropsychological tests. Seventeen of the 45 met criteria for PTSD. The Paced Auditory Serial Addition Test (Frencham, Fox, & Mayberry, 2005; Spreen & Strauss, 1998) was the primary outcome measure. Two-sided, 2-sample t tests were used to compare scores between groups of interest. Presence of mTBI symptoms did not impact test performance. In addition, no significant differences between soldiers with and without PTSD were identified. Standard neuropsychological assessment may not increase understanding about impairment associated with mTBI symptoms. Further research in this area is indicated.

Varenicline and P50 auditory gating in medicated schizophrenic patients: a pilot study.

Most schizophrenic patients have a deficit in auditory sensory gating that appears to be mediated by the alpha-7 nicotinic receptor. This pilot study examines the effects of varenicline, an alpha-7 agonist, on the P50 auditory evoked potential in six schizophrenic patients. The study was canceled because of concerning side effects consistent with those reported by the FDA. However, in this small group of subjects, varenicline did not consistently enhance P50 auditory gating.

Suicidality and veterans with a history of traumatic brain injury: precipitants events, protective factors, and prevention strategies.

OBJECTIVES: To increase understanding regarding precipitating and preventative factors of suicidal behavior and to highlight past experiences and recommendations regarding services aimed at suicide prevention among Veterans with a history of traumatic brain injury (TBI). STUDY DESIGN: Qualitative. PARTICIPANTS: Sample of 13 Veterans with a history of TBI, and a history of clinically significant suicidal ideation or behavior. METHOD: In-person interviews were conducted and data were analyzed using a hermeneutic approach. RESULTS: Shared precipitants noted included loss-of-self post-TBI, cognitive sequelae, and psychiatric and emotional disturbances. Common protective factors noted included social supports, a sense of purpose regarding the future, religion and spirituality, and mental health care. Means of improving care were also identified (e.g., increasing the availability of services and mental health professionals' knowledge regarding TBI, providing more structured treatment). CONCLUSIONS: Findings highlight potential areas of importance in the assessment and treatment of suicidal Veterans with a history of TBI. Recommendations regarding means of improving care are also presented.

Utility of the trauma symptom inventory for the assessment of post-traumatic stress symptoms in veterans with a history of psychological trauma and/or brain injury.

Correspondence of three core Trauma Symptom Inventory (TSI) posttraumatic stress disorder (PTSD) scales (Intrusive Experiences, Defensive Avoidance, and Anxious Arousal) and the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-IV) PTSD module were examined among 72 veterans with traumatic brain injury (TBI), PTSD, or both conditions. Subjects were classified into PTSD only, TBI only, or co-occurring PTSD and TBI groups based on TBI assessment and SCID-IV PTSD diagnosis. Linear regression was used to model TSI T-Scores as a function of group. Scores on all three scales significantly differed between the TBI and PTSD groups (PTSD only and co-occurring PTSD and TBI) in the expected direction. Study findings indicate that despite the potential overlap of symptoms between PTSD and TBI, the TSI appears to be a useful measure of trauma-related symptoms in veterans who may also have a TBI, particularly mild TBI. Limitations and areas for future research are discussed.

An exploratory study of neuroimaging, neurologic, and neuropsychological findings in veterans with traumatic brain injury and/or posttraumatic stress disorder.

Seventy-two veterans with traumatic brain injury (TBI), posttraumatic stress disorder (PTSD), or both participated in assessment procedures to evaluate between group differences. Half the sample was randomly selected for magnetic resonance imaging (MRI). Neurologic examinations were conducted using the Neurologic Rating Scale (NRS). Neuropsychological measures included the Paced Auditory Serial Addition Test (PASAT), Rey Auditory Verbal Learning Test (RAVLT), Conners' Continuous Performance Test II (CPT II), and Halstead Impairment Index (HII) including the Booklet Category Test (BCT). Data were analyzed using linear regression. Participants with moderate/ severe TBI were significantly more likely to have trauma-related imaging findings, and more severe TBI predicted lower scores on the NRS. No significant between-group differences were identified on the HII, PASAT, RAVLT, or CPT II. TBI group performance was significantly better on the BCT. More severe TBI predicted abnormal imaging findings and lower NRS scores. Hypothesized between-group differences on neuropsychological measures were not supported.

Family-focused therapy via videoconferencing.

A 30-year-old veteran with a diagnosis of schizoaffective disorder and his mother were referred for family-focused therapy (FFT), an empirically-supported, manual-based treatment. The veteran had had multiple hospitalizations and experienced chronic auditory hallucinations for self-harm. Minor modifications to FFT were made for implementation via videoconferencing (at a bandwidth of 384 kbit/s). This may have enhanced the treatment by making the process of communication and problem-solving more explicit. The course of FFT was successfully completed, and the veteran and family showed a high level of satisfaction with care as well as improved medication adherence, good quality of life, high levels of hope, good interpersonal functioning, and very mild negative and positive psychiatric symptoms. This veteran had previous exposure to telemental health, which may have influenced his willingness to receive tele-FFT and perhaps affected the outcome of the case. The ability to provide this type of service to people in rural areas is important.

Sensitivity and specificity of the Beck Depression Inventory-II in persons with traumatic brain injury.

OBJECTIVES: Our objective was to examine the Beck Depression Inventory-II (BDI-II) in a traumatic brain injury (TBI) sample using a receiver operating characteristic (ROC) curve to determine how well the BDI-II identifies depression. An ROC curve allows for analysis of the sensitivity and specificity of a diagnostic test using various cutoff points to determine the number of true positives, true negatives, false positives, and false negatives. DESIGN: This was a secondary analysis of data gathered from an observational study. We examined BDI-II scores in a sample of 52 veterans with remote histories of TBI. SETTING: This study was completed at a Veterans Affairs (VA) Medical Center. PARTICIPANTS: Participants were veterans eligible to receive VA health care services. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Outcome measures included the BDI-II and the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-IV). RESULTS: We generated an ROC curve to determine how well the BDI-II identifies depression using the SCID-IV as the criterion standard for diagnosing depression, defined here as a diagnosis of major depressive disorder. Results indicated a cutoff score of at least 19 if one has a mild TBI or at least 35 if one has a moderate or severe TBI. These scores maximize sensitivity (87%) and specificity (79%). CONCLUSIONS: Clinicians working with persons with TBI can use the BDI-II to determine whether depressive symptoms warrant further assessment.

Suicide among incarcerated veterans.

Both veterans and jail/prison inmates face an increased risk of suicide. The incarcerated veteran sits at the intersection of these two groups, yet little is known about this subpopulation, particularly its risk of suicide. A Pubmed/Medline/PsycINFO search anchored to incarcerated veteran suicide, veteran suicide, suicide in jails/prisons, and veterans incarcerated from 2000 to the present was performed. The currently available literature does not reveal the suicide risk of incarcerated veterans, nor does it enable meaningful estimates. However, striking similarities and overlapping characteristics link the data on veteran suicide, inmate suicide, and incarcerated veterans, suggesting that the veteran in jail or prison faces a level of suicide risk beyond that conferred by either veteran status or incarceration alone. There is a clear need for a better characterization of the incarcerated veteran population and the suicide rate faced by this group. Implications for clinical practice and future research are offered.

Psychiatric hospitalization and veterans with traumatic brain injury: a retrospective study.

OBJECTIVE: To determine risk factors for psychiatric hospitalization after traumatic brain injury (TBI) in veterans. SUBJECTS AND PROCEDURES: Medical records of 96 veterans with histories of TBI (17 mild, 33 moderate, and 46 severe) were reviewed for information concerning psychiatric history, including hospitalization and substance misuse. RESULTS: Subjects with a history of problematic drug and alcohol use had a significantly higher probability of psychiatric hospitalization than those without such a history. Gender, age, problematic alcohol use without problematic drug use, injury severity, time since injury, years of follow-up, and a history of psychiatric symptoms (including those attributed to general medical conditions) were not identified as significant risk factors. Ninety-one veterans (95%) had a history of psychiatric difficulty. In addition, the probability of post-TBI problematic drug and alcohol use, given a pre-TBI history of such use, was significantly higher than the probability given no history. CONCLUSIONS: Veterans with problematic drug and alcohol use are at increased risk for psychiatric hospitalization after TBI. In addition, the likelihood of problematic post-TBI drug and alcohol use was significantly greater for those with a preinjury history. Ninety-five percent of veterans in the current sample endorsed lifetime histories of psychiatric difficulty. These findings highlight the need for evidence-based means of psychiatric and/or substance abuse treatment of those with a history of TBI.

Tobacco use and cessation in psychiatric disorders: National Institute of Mental Health report.

The National Institute of Mental Health (NIMH) convened a meeting in September 2005 to review tobacco use and dependence and smoking cessation among those with mental disorders, especially individuals with anxiety disorders, depression, or schizophrenia. Smoking rates are exceptionally high among these individuals and contribute to the high rates of medical morbidity and mortality in these individuals. Numerous biological, psychological, and social factors may explain these high smoking rates, including the lack of smoking cessation treatment in mental health settings. Historically, "self-medication" and "individual rights" have been concerns used to rationalize allowing ongoing tobacco use and limited smoking cessation efforts in many mental health treatment settings. Although research has shown that tobacco use can reduce or ameliorate certain psychiatric symptoms, overreliance on the self-medication hypothesis to explain the high rates of tobacco use in psychiatric populations may result in inadequate attention to other potential explanations for this addictive behavior among those with mental disorders. A more complete understanding of nicotine and tobacco use in psychiatric patients also can lead to new psychiatric treatments and a better understanding of mental illness. Greater collaboration between mental health researchers and nicotine and tobacco researchers is needed to better understand and develop new treatments for cooccurring nicotine dependence and mental illness. Despite an accumulating literature for some specific psychiatric disorders and tobacco use and cessation, many unstudied research questions remain and are a focus and an emphasis of this review.

A review of "suicidal intent" within the existing suicide literature.

The results of a systematic literature review that investigated suicide intent are presented. Of the 44 relevant articles identified, 17 investigated the relationships between various suicide risk factors and suicide intent and 25 publications investigated the relationships between suicide intent and various suicide outcomes. Despite recent advancements in the definition and nomological validity of suicide intent, a high degree of variability in the empirical measurement and analysis of suicide intent was found. Such variability limits future research related to measuring suicidal risk and outcomes, reporting suicide intent, or the meaningful comparison of diagnostic approaches or treatments across multiple studies.

Qigong stress reduction in hospital staff.

OBJECTIVE: The aim of this study was to investigate the effectiveness of a qigong training program in reducing stress in hospital staff. METHODS: Subjects were randomly assigned to a 6-week intervention of either qigong practice (n = 16) or a waiting list (n = 21). The primary measure of stress was the Perceived Stress Scale. Secondary measures included the Short Form 36 (SF-36) quality-of-life measure and a 100-mm analog pain scale. RESULTS: The qigong group demonstrated a statistically significant reduction of perceived stress compared to the control group (p = 0.02). On the Social Interaction subscale of the SF-36, the qigong group demonstrated greater improvement compared to controls (p = 0.04). Within-groups analyses demonstrated that the qigong group (p = 0.03), but not the control group, experienced a significant reduction of pain intensity. A regression analysis demonstrated an association between higher baseline stress levels and greater improvement within the qigong group (R(2) = 0.34; p = 0.02). CONCLUSIONS: These results suggest that short-term exposure to qigong was effective in reducing stress in hospital staff. Further studies are needed to evaluate the possible effectiveness of qigong in reducing pain and in improving quality of life.

Proof-of-concept trial of an alpha7 nicotinic agonist in schizophrenia.

CONTEXT: The alpha7 nicotinic acetylcholine receptor gene, CHRNA7, is associated with genetic transmission of schizophrenia and related cognitive and neurophysiological sensory gating deficits. Cognitive dysfunction is responsible for significant psychosocial disability in schizophrenia. Nicotine, a low-potency agonist at the alpha7 receptor, has some positive effects on neurophysiological and neurocognitive deficits associated with schizophrenia, which suggests that more effective receptor activation might meaningfully enhance cognition in schizophrenia. OBJECTIVES: To determine if 3-[(2,4-dimethoxy)benzylidene]anabaseine (DMXB-A), a natural alkaloid derivative and a partial alpha7 nicotinic cholinergic agonist, significantly improves neurocognition, and to assess, by effects on P50 auditory evoked potential inhibition, whether its neurobiological actions are consistent with activation of alpha7 nicotinic receptors. DESIGN: Randomized, double-blind crossover trial of 2 drug doses and 1 placebo. SETTING: General clinical research center. PATIENTS: Twelve persons with schizophrenia who did not smoke and were concurrently treated with antipsychotic drugs. One person was withdrawn because of a transient decrease in white blood cell count. INTERVENTION: Administration of DMXB-A. MAIN OUTCOME MEASURES: Total scale score of the Repeatable Battery for the Assessment of Neuropsychological Status and P50 inhibitory gating. RESULTS: Significant neurocognitive improvement was found on the Repeatable Battery for the Assessment of Neuropsychological Status total scale score, particularly for the lower DMXB-A dose compared with placebo. Effects were greater than those of nicotine in a similar study. Significant improvement in P50 inhibition also occurred. Patients generally tolerated the drug well. CONCLUSIONS: An alpha7 nicotinic agonist appears to have positive effects on neurocognition in persons with schizophrenia. Longer trials are needed to determine the clinical utility of this novel treatment strategy.

Distinct M50 and M100 auditory gating deficits in schizophrenia.

The time course of the schizophrenia auditory gating deficit may provide clues to mechanisms of impaired cognition. Magnetoencephalography was recorded during a standard paired-click paradigm. Using source strength of the M50 and M100 components for each click, calculated from dipole locations identified as underlying each component for the first click, a ratio of the second divided by the first was used to measure gating. Patients showed a left-hemisphere gating deficit in M50 and a bilateral gating deficit in M100. Hypothesizing that an early deficit may affect later processing, hierarchical regression was used to examine variance shared between the components. A left-hemisphere M100 gating deficit was coupled with the left M50 gating deficit. In contrast, a right-hemisphere M100 gating deficit was unrelated to M50 gating in either hemisphere. Investigations of interhemisphere gating relations may clarify group differences in regional connectivity and their role in gating.

M50 sensory gating predicts negative symptoms in schizophrenia.

Impaired auditory sensory gating is considered characteristic of schizophrenia and a marker of the information processing deficit inherent to that disorder. Predominance of negative symptoms also reflects the degree of deficit in schizophrenia and is associated with poorer pre-morbid functioning, lower IQ, and poorer outcomes. However, a consistent relationship between auditory sensory gating and negative symptoms in schizophrenia has yet to be demonstrated. The absence of such a finding is surprising, since both impaired auditory gating and negative symptoms have been linked with impaired fronto-temporal cortical function. The present study measured auditory gating using the P50 event related potential (ERP) in a paired-click paradigm and capitalized on the relative localization advantage of magnetoencephalography (MEG) to assess auditory sensory gating in terms of the event related field (ERF) M50 source dipoles on bilateral superior temporal gyrus (STG). The primary hypothesis was that there would be a positive correlation between lateralized M50 auditory sensory gating measures and negative symptoms in patients with schizophrenia. A standard paired-click paradigm was used during simultaneous EEG and MEG data collection to determine S2/S1 sensory gating ratios in a group of 20 patients for both neuroimaging techniques. Participants were administered the Schedule for the Assessment of Negative Symptoms (SANS), the Positive and Negative Symptom Scale (PANSS), and the Calgary Depression Scale for Schizophrenia. Consistent with previous reports, there was no relationship between ERP P50 sensory gating and negative symptoms. However, right (not left) hemisphere ERF M50 sensory gating ratio was significantly and positively correlated with negative symptoms. This finding is compatible with information processing theories of negative symptoms and with more recent findings of fronto-temporal abnormality in patients with predominantly negative symptoms.

Improved p50 auditory gating with ondansetron in medicated schizophrenia patients.

OBJECTIVE: Most schizophrenia patients have a deficit in auditory sensory gating, which appears to be mediated by the alpha-7 nicotinic receptor, that is not improved with conventional antipsychotic treatment. This study examined the effects of ondansetron, a highly selective 5-HT3 antagonist, on the P50 auditory evoked potential. METHOD: Eight medicated outpatients with schizophrenia were given either ondansetron (16 mg) or placebo in a double-blind, placebo-controlled design. Evoked potentials were recorded at baseline and 1 hour, 2 hours, and 3 hours after receipt of drug. RESULTS: There was a highly significant improvement in P50 gating after ondansetron treatment. The maximal treatment difference was at 2 hours posttreatment (ondansetron: mean=41.4%, SD=39.7%; placebo: mean=80.2%, SD=21.3%). CONCLUSIONS: Ondansetron significantly enhanced P50 auditory gating in schizophrenia patients treated with typical antipsychotics.

Varied effects of atypical neuroleptics on P50 auditory gating in schizophrenia patients.

OBJECTIVE: Sensory gating deficits found in schizophrenia can be assessed by using a paired auditory stimulus paradigm to measure auditory evoked response. The ratio of the P50 response amplitude of the second or test stimulus to that of the first or conditioning stimulus is expressed as a percentage. Normal subjects generally suppress the second response and typically have ratios of less than 40%. Subjects with schizophrenia and half their first-degree relatives have deficits in sensory gating, with P50 ratios that are generally greater than 50%. Treatment with typical neuroleptics does not reverse this deficit. However, previous studies have shown that treatment with clozapine, an atypical neuroleptic, ameliorates this deficit in clinically responsive patients. This study sought to determine whether other atypical neuroleptics improve P50 ratios. METHOD: P50 evoked potential recordings were obtained from 132 patients with schizophrenia and 177 healthy comparison subjects. Eighty-eight patients were being treated with atypical neuroleptics (clozapine [N=26], olanzapine [N=31], risperidone [N=22], and quetiapine [N=9]). Thirty-four patients were taking typical neuroleptics, and 10 were unmedicated. RESULTS: Healthy subjects exhibited P50 suppression that was significantly better than the schizophrenia patients receiving typical neuroleptics (mean=19.8% [SD=21.0%] versus 110.1% [SD=87.9%]). Patients receiving atypical neuroleptics had a mean P50 ratio that fell between these two means (mean=70.4%, SD=53.7%). When patients treated with different atypical neuroleptics were compared, only the clozapine group had mean P50 ratios that were in the normal range. All other groups exhibited auditory P50 response inhibition that was significantly poorer than that of the healthy subjects. CONCLUSIONS: Improvement in P50 gating appears to be greatest in patients treated with clozapine.