Apolipoprotein E Isoform-specific changes related to stress and trauma exposure.

Post-Traumatic Stress Disorder (PTSD) is a highly prevalent mental health disorder. Due to the high level of variability in susceptibility and severity, PTSD therapies are still insufficient. In addition to environmental exposures, genetic risks play a prominent role and one such factor is apolipoprotein E. The protein (apoE) is functionally involved in cholesterol transport and metabolism and exists as 3 major isoforms in humans: E2, E3, and E4. To model the role of apolipoprotein E isoform in stress-related changes in behavior and cognition, female and male mice (3-5 months of age) expressing E2, E3, or E4 were used. Mice were either placed into control groups or exposed to chronic variable stress (CVS), which has been shown to induce PTSD-like behavioral and neuroendocrine changes. E2 mice showed a unique response to CVS compared to E3 and E4 mice that included impaired spatial learning and memory, increased adrenal gland weight, and no increase in glucocorticoid receptor protein levels (normalized to apoE levels). In addition, the cholesterol metabolite 7-ketocholesterol was elevated in the cortex after CVS in E3 and E4, but not E2 female mice. E2 confers unique changes in behavioral, cognitive, and biomarker profiles after stress exposure and identify 7-ketocholesterol as a possible novel biomarker of the traumatic stress response. We further explored the relationship between E2 and PTSD in an understudied population by genotyping 102 patients of Cambodian and Vietnamese ethnicity. E2 carriers demonstrated a higher odds ratio of having a PTSD diagnosis compared to E3/E3 carriers, supporting that the E2 genotype is associated with PTSD diagnosis after trauma exposure in this population.

Experiencing Mental Illness: Suffering, Hope, and Healing.

The experience of mental illness can be painful and isolating for those suffering in silence. Early symptoms frequently are confusing and disorienting for individuals and families, and stigma towards mental illness in societies across the globe contributes to further isolation from sources of support during the healing process. The evocative personal stories from a variety of cultures in this symposium provide a window into universal elements of the experience of mental illness, with the accompanying fear, shame, and stigma. The stories effectively illustrate the tension between personal autonomy and reliance on others, and the importance of trust in self and others in forming and maintaining a core identity. The stories also sensitively highlight the importance of resilience and persistence in the healing process, along with the essential role of social relationships and support from family, friends, and healers in building a stable identity and hope for the future.

The association between gabapentin and suicidality in bipolar patients.

The aims of this study were to assess the association between gabapentin and suicidality in patients diagnosed with bipolar disorder (BD) and to determine whether the risk is greater relative to patients prescribed lithium. This retrospective observational study utilizes US population-based claims data assembled by PharMetrics Inc., comprising 47 918 patients diagnosed with BD. Patients were included if they were at least 18 years old and initiated a new monotherapy prescription of either gabapentin (n=2421) or lithium (n=3101). Patients were followed for up to 1 year. Gabapentin patients contributed 915.8 person-years (PY) of follow-up time; lithium patients contributed 1421.3 PY. There were 21 suicide/self-harm events in the gabapentin group and 16 in the lithium group. Unadjusted incidence rates were 22.9 and 11.3/1000 PY in the gabapentin and lithium groups, respectively (P=0.03). After adjusting for concomitant medications, comorbid diagnoses, age, sex, and history of suicide/self-harm, the hazard ratio was 2.3 (95% confidence interval: 1.2-4.5). A propensity score-matched analysis accounting for pre-existing illnesses and medications supports this finding, with an adjusted hazard ratio of 2.1 (95% confidence interval: 1.02-4.5). Relative to lithium, the use of gabapentin is significantly associated with a doubling of the risk of suicidality in patients diagnosed with BD.

The influence of developmental, education, and mentorship experiences on career paths in cultural psychiatry.

Career paths in cultural psychiatry and other areas of medicine often are influenced by a combination of developmental, academic and training experiences. One of the satisfactions for the cultural psychiatrist is the opportunity to integrate lifelong interests that are not central to medical training, such as anthropology, philosophy, history or geography into one's daily work and career path, and this is not necessarily just applicable to clinical work or research. A background in social sciences can be very helpful in navigating the political and interpersonal challenges of working in an academic medical center or designing effective education programs across the career spectrum in medicine. This article traces the development of my career in academic cultural psychiatry and illustrates the way my clinical and academic interests were influenced both by early developmental and educational experiences and by positive career experiences as a clinician, teacher and researcher in the context of effective mentorship and professional peer relationships. The future of cultural psychiatry is exciting and its continued growth will be dependent on effective nurturance of young physicians who have a broad vision of the important place of cultural psychiatry and how it influences medicine, mental health, and society at large.

Modelo biopsicosocial en el manejo del trastorno por estrés postraumático en inmigrantes: "Centro de tratamiento de personas sometidas a tortura de Oregón". ¿Se necesitan centros específicos en nuestro país? / No disponible

La inmigración es un proceso en auge y los inmigrantes una población potencialmente de riesgo, ya que parte de ellos han estado expuestos a situaciones traumáticas, por lo que debemos de estar familiarizados con el diagnóstico y tratamiento del trastorno por estrés postraumático (TPET). Desde 1977 existe en Estados Unidos un Programa de Psiquiatría Transcultural y un Centro dedicado al tratamiento de refugiados de países donde ha existido violencia política. Basándonos en su experiencia, que contrastamos durante una estancia de 3 meses durante el período de formación MIR, hemos revisado las características diagnósticas del TPET, el funcionamiento del Centro y sus enfoques terapéuticos. Las manifestaciones del TPET varían en el tiempo y con las circunstancias sociolaborales y familia-res del paciente, por lo que un modelo biopsicosocial es recomendable en el tratamiento de estos pacientes (AU)

The migrant population in Spain is increasing rapidly. Potentially, migrants constitute population at risk because some of them may have been exposed to traumatic situations. Therefore, we should become familiar with the diag-nosis and treatment of post-traumatic stress disorder (PTSD) in this po-pulation. Since 1977, the Intercultural Psychiatric Program and the Torture Treatment Center of Oregon, USA, specializes in the treatment of refugees from countries that have suffered poli-tical violence. Based on their experience, which the senior author observed for 3 months during his MIR training, we reviewed the diagnostic characteristics of PTSD and the Center’s structure and therapeutic approaches. The ma-nifestation of PTSD varies over time, and depends on the social, familial and working status of the patient. Therefore, a biopsychosocial model is recommended for the treatment of these patients and a similar model is proposed for treatment of PTSD among the migrant population in Spain (AU)

Cross-cultural psychiatric residency training: the Oregon experience.

OBJECTIVE: The purpose of this article is to describe the goals and structure of cross-cultural psychiatric training at Oregon Health and Science University (OHSU). This training in core knowledge, skills, and attitudes of cultural psychiatry over the past three decades has included medical students, residents, and fellows, along with allied mental health personnel. The curriculum includes both didactic sessions devoted to core topics in the field and varied clinical experiences in community settings and the Intercultural Psychiatric Program under the supervision of experienced academic faculty. METHODS: The authors review the central elements of the training experiences and include a detailed description of the core clinical settings and experiences. RESULTS: At the conclusion of their clinical experiences, trainees have specialized cross-cultural psychiatric knowledge and skills, including treatment of refugees and immigrants, sociocultural variables that influence the assessment and treatment of a wide range of psychiatric conditions, and comfort with cultural dynamics that influence both the doctor/patient relationship and collaboration with a wide range of mental health professionals. CONCLUSION: Because of rapid demographic changes in the U.S. population, providing cross-cultural training for students, residents, and fellows is an essential foundation for the education of the next generation of clinicians and health care leaders. OHSU has provided a long-term model for this training in a busy clinical and academic setting that places an emphasis on multidisciplinary and multicultural collaboration.

Pharmacologic reduction of CNS noradrenergic activity in PTSD: the case for clonidine and prazosin.

This article reviews the neurobiologic rationale for and presents clinical guidance concerning the use of medications that reduce central nervous system noradrenergic activity in the treatment of intrusive symptoms of posttraumatic stress disorder. The authors reviewed neurobiological studies, nonclinical studies using animal models, clinical case reports, open-label drug studies, and blinded, placebo-controlled drug studies. This review of the basic science and clinical literature, and the authors' clinical experience with culturally and demographically diverse populations, indicate that clonidine and prazosin can play a useful role in treating sleep disturbance and hyperarousal in posttraumatic stress disorder, with minimal adverse effects and low financial cost.

Religion and spirituality in psychiatric care: looking back, looking ahead.

Cultural psychiatry has been an important contributor to the enhanced dialogue between psychiatry and religion in the past couple of decades. During this time, religion and spirituality have become more prominent in mainstream psychiatry in a number of areas of study and clinical care, including refugee and immigrant health, trauma and loss, psychotherapy, collaboration with clergy, bioethics, and psychiatric research. In looking towards the future, there is a great deal of promise for future enhancement of the study of religion and spirituality in psychiatric education, research, and clinical care.

Cultural considerations in the criminal law: the sentencing process.

In forensic psychiatry, there is increasing recognition of the importance of culture and ethnicity in the criminal justice process as the population becomes more culturally diverse. However, there has been little consideration of the role of cultural factors in the trial process for criminal defendants, particularly in the sentencing phase of trial. Using a capital murder case study, this article explores the role of cultural forensic psychiatric consultation, focusing on the sentencing phase of trial as the place where the full scope and power of a cultural evaluation can be brought most effectively to the attention of the court. Cultural psychiatric perspectives can enrich a core forensic evaluation and be maximally helpful to the court, by exploring family dynamics and psychological health influenced by cultural history, immigrant and refugee experiences, and sociocultural environment. Specific recommendations and cautions for effective cultural consultation in forensic psychiatry are discussed.

A ten-year treatment outcome study of traumatized Cambodian refugees.

The purpose of this study was to assess treatment outcome among 23 severely traumatized Cambodian refugee patients with posttraumatic stress disorder who had been in continuous treatment for 10 or more years. Primary outcome parameters were symptom severity, social and vocational disability, and subjective quality of life. All patients were interviewed using standard assessment tools by a research psychiatrist not connected with the treatment, and charts were reviewed for past and current traumas and for treatment history. There was a wide range of current posttraumatic stress disorder symptom scores, but current depression scores were very low. Thirteen patients were judged to have good outcomes, and 10 had relatively poor outcomes. Reported degree of previous trauma and demographic factors did not distinguish between the two outcome groups. Sixty percent of patients greatly improved. However, even with comprehensive continuous treatment over a period of 10 or more years, a substantial minority was still impaired.