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Rocky Mountain MIRECC for Suicide Prevention

Updated: 23 January 2017

Publications - 2016

Barnes, S. M., Bahraini, N. H., Forster, J. E., Stearns-Yoder, K. A., Hostetter, T. A., Smith, G., Nagamoto, H. T. and Nock, M. K. (2016), Moving Beyond Self-Report: Implicit Associations about Death/Life Prospectively Predict Suicidal Behavior among Veterans. Suicide and Life-Threat Behavi. doi: 10.1111/sltb.12265
Reliance on self-report limits clinicians' ability to accurately predict suicidal behavior. In this study the predictive validity of an objective measure, the death/suicide Implicit Association Test (d/sIAT), was tested among psychiatrically hospitalized veterans. Following acute stabilization, 176 participants completed the d/sIAT and traditional suicide risk assessments. Participants had similar d/sIAT scores regardless of whether they had recently attempted suicide. However, d/sIAT scores significantly predicted suicide attempts during the 6-month follow-up above and beyond other known risk factors for suicidal behavior (OR = 1.89; 95% CI: 1.15–3.12; based on 1SD increase). The d/sIAT may augment the accuracy of suicide risk assessment.
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Driskell LD, Starosta AJ, Brenner LA. Clinical utility and measurement characteristics of the Hospital Anxiety and Depression Scale for individuals with traumatic brain injury. Rehabil Psychol. 2016 Feb;61(1):112-3. doi:10.1037/rep0000079.
This Rehabilitation Measures Database summary provides a review of the psychometric properties of the HADS in individuals with TBI. A full review of the HADS as well as reviews of over 330 other instruments can be found at www.rehabmeasures.org.
(PsycINFO Database Record © 2016 APA, all rights reserved).
The full text of this article is available for free online.
Hebert JR, Kindred JH, Bucci M, Tuulari JJ, Brenner LA, Forster JE, Koo PJ, Rudroff T. Cognitive-Motor Related Brain Activity During Walking: Differences Between Men and Women With Multiple Sclerosis. Arch Phys Med Rehabil. 2016 Jan;97(1):61-6. doi: 10.1016/j.apmr.2015.09.015.
OBJECTIVE: To determine if sex differences in glucose uptake, a marker of brain activity, are present in brain regions that facilitate walking performance in persons with multiple sclerosis (MS). DESIGN: Cross-sectional, observational pilot. SETTING: University laboratory. PARTICIPANTS: Positron emission tomography with fluorine-18-labeled deoxyglucose (FDG) was performed on persons with MS and healthy controls (4 men and 4 women per group; N=16) after a 15-minute walking test. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Brain activity was quantified as the mean standardized uptake value (SUV). RESULTS: The mean SUV was significantly lower in the thalamus (P=.029) and cerebellum (P=.029) for men with MS compared with women with MS, but not for the prefrontal (P=.057) or frontal (P=.057) cortices. Similar nonsignificant trends were found for healthy controls. No mean SUV group × sex interaction effects were found between the MS and healthy control groups (all P>.05). CONCLUSIONS: To our knowledge, this is the first study of brain activity sex differences based on FDG uptake in persons with MS during walking. Significantly less FDG uptake in the thalamus and cerebellum brain regions important for walking performance was found in men with MS compared with women with MS; however, these comparisons were not significantly different in the healthy control group. No differences in FDG uptake were found between the MS and healthy control groups in any of the brain regions examined. Results from this study provide pilot data for larger studies aimed at identifying underlying mechanisms responsible for accelerated disability in men with MS. Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.
KEYWORDS: Brain; Multiple sclerosis; Positron-emission tomography; Rehabilitation
Unfortunately, the full text of this article is behind a pay wall.
Hernández TD, Brenner LA, Walter KH, Bormann JE, Johansson B. Complementary and alternative medicine (CAM) following traumatic brain injury (TBI): Opportunities and challenges. Brain Res. 2016 Jan 21. pii: S0006-8993(16)30002-6. doi: 10.1016/j.brainres.2016.01.025.
Traumatic brain injury (TBI) is highly prevalent and occurs in a variety of populations. Because of the complexity of its sequelae, treatment strategies pose a challenge. Given this complexity, TBI provides a unique target of opportunity for complementary and alternative medicine (CAM) treatments. The present review describes and discusses current opportunitites and challenges associated with CAM research and clinical applications in civilian, veteran and military service populations. In addition to a brief overview of CAM, the translational capacity from basic to clinical research to clinical practice will be described. Finally, a systematic approach to developing an adoptable evidence base, with proof of effectiveness based on the literature will be discussed. Inherent in this discussion will be the methodological and ethical challenges associated with CAM research in those with TBI and associated comorbidities, specifically in terms of how these challenges relate to practice and policy issues, implementation and dissemination. This article is part of a Special Issue entitled SI:Brain injury and recovery. Copyright © 2016 Elsevier B.V. All rights reserved.
KEYWORDS: Acupressure; Complementary and alternative medicine (CAM); Mantram; Meditation; Mindfulness based stress reduction (MBSR); Traumatic brain injury
Unfortunately, the full text of this article is behind a pay wall.
Kessler RC, van Loo HM, Wardenaar KJ, Bossarte RM, Brenner LA, Ebert DD, de Jonge P, Nierenberg AA, Rosellini AJ, Sampson NA, Schoevers RA, Wilcox MA, Zaslavsky AM. Using patient self-reports to study heterogeneity of treatment effects in major depressive disorder. Epidemiol Psychiatr Sci. 2016 Jan 26:1-15. [Epub ahead of print] PubMed PMID: 26810628.
BACKGROUNDS: Clinicians need guidance to address the heterogeneity of treatment responses of patients with major depressive disorder (MDD). While prediction schemes based on symptom clustering and biomarkers have so far not yielded results of sufficient strength to inform clinical decision-making, prediction schemes based on big data predictive analytic models might be more practically useful. METHOD: We review evidence suggesting that prediction equations based on symptoms and other easily-assessed clinical features found in previous research to predict MDD treatment outcomes might provide a foundation for developing predictive analytic clinical decision support models that could help clinicians select optimal (personalised) MDD treatments. These methods could also be useful in targeting patient subsamples for more expensive biomarker assessments. RESULTS: Approximately two dozen baseline variables obtained from medical records or patient reports have been found repeatedly in MDD treatment trials to predict overall treatment outcomes (i.e., intervention v. control) or differential treatment outcomes (i.e., intervention A v. intervention B). Similar evidence has been found in observational studies of MDD persistence-severity. However, no treatment studies have yet attempted to develop treatment outcome equations using the full set of these predictors. Promising preliminary empirical results coupled with recent developments in statistical methodology suggest that models could be developed to provide useful clinical decision support in personalised treatment selection. These tools could also provide a strong foundation to increase statistical power in focused studies of biomarkers and MDD heterogeneity of treatment response in subsequent controlled trials. CONCLUSIONS: Coordinated efforts are needed to develop a protocol for systematically collecting information about established predictors of heterogeneity of MDD treatment response in large observational treatment studies, applying and refining these models in subsequent pragmatic trials, carrying out pooled secondary analyses to extract the maximum amount of information from these coordinated studies, and using this information to focus future discovery efforts in the segment of the patient population in which continued uncertainty about treatment response exists.
KEYWORDS: Depression; epidemiology; evidence-based psychiatry; research design and methods; treatment allocation
Unfortunately, the full text of this article is behind a pay wall.
Kessler RC, van Loo HM, Wardenaar KJ, Bossarte RM, Brenner LA, Cai T, Ebert DD, Hwang I, Li J, de Jonge P, Nierenberg AA, Petukhova MV, Rosellini AJ, Sampson NA, Schoevers RA, Wilcox MA, Zaslavsky AM. Testing a machine-learning algorithm to predict the persistence and severity of major depressive disorder from baseline self-reports. Mol Psychiatry. 2016 Jan 5. doi: 10.1038/mp.2015.198.
Heterogeneity of major depressive disorder (MDD) illness course complicates clinical decision-making. Although efforts to use symptom profiles or biomarkers to develop clinically useful prognostic subtypes have had limited success, a recent report showed that machine-learning (ML) models developed from self-reports about incident episode characteristics and comorbidities among respondents with lifetime MDD in the World Health Organization World Mental Health (WMH) Surveys predicted MDD persistence, chronicity and severity with good accuracy. We report results of model validation in an independent prospective national household sample of 1056 respondents with lifetime MDD at baseline. The WMH ML models were applied to these baseline data to generate predicted outcome scores that were compared with observed scores assessed 10-12 years after baseline. ML model prediction accuracy was also compared with that of conventional logistic regression models. Area under the receiver operating characteristic curve based on ML (0.63 for high chronicity and 0.71-0.76 for the other prospective outcomes) was consistently higher than for the logistic models (0.62-0.70) despite the latter models including more predictors. A total of 34.6-38.1% of respondents with subsequent high persistence chronicity and 40.8-55.8% with the severity indicators were in the top 20% of the baseline ML-predicted risk distribution, while only 0.9% of respondents with subsequent hospitalizations and 1.5% with suicide attempts were in the lowest 20% of the ML-predicted risk distribution. These results confirm that clinically useful MDD risk-stratification models can be generated from baseline patient self-reports and that ML methods improve on conventional methods in developing such models. Molecular Psychiatry advance online publication, 5 January 2016; doi:10.1038/mp.2015.198.
The full text of this article is available for free online.
Matarazzo BB, Signoracci GM, Brenner LA, Olson-Madden JH. Barriers and Facilitators in Providing Community Mental Health Care to Returning Veterans with a History of Traumatic Brain Injury and Co-occurring Mental Health Symptoms. Community Ment Health J. 2016 Feb;52(2):158-64. doi: 10.1007/s10597-015-9926-9.
As Veterans from recent conflicts return from deployments, increasing numbers are seeking care for physical (e.g., history of traumatic brain injury) and mental health (e.g., depression, anxiety) symptoms. Data suggest that only about half of recent Veterans are seeking care within the Veterans Health Administration. As such, providers within the community are likely to require additional training to meet the unique needs of these Veterans and their families. Towards this end, meetings were held with administrators and clinicians at Colorado Community Mental Health Centers (CMHCs) to identify current barriers and facilitators, as they relate to working with Veterans with a history of TBI and co-occurring mental health conditions. On-whole, CMHC employees had limited experience with providing care to the cohort of interest. Additional training will assist with increasing capacity and a web-based toolkit was developed to facilitate the transfer of knowledge (www.mirecc.va.gov/visn19/tbi_toolkit).
KEYWORDS: Mental health; Providers; Traumatic brain injury; Veterans
The full text of this article is available for free online.
Monteith, L.L., Bahraini, N.B., Matarazzo, B.B., Gerber, H., Soberay, K.A., & Forster, J.E. (2016). The Influence of Gender on Suicidal Ideation following Military Sexual Trauma among Veterans in the Veterans Health Administration. Psychiatry Research, July, doi:10.1016/j.psychres.2016.07.036
No studies have examined whether military sexual trauma, as measured and defined within the Veterans Health Administration (VHA), is associated with suicidal ideation among Veterans in VHA care, when taking prior suicide attempts into account. Research regarding the role of gender in this association is also limited. The present study examined: (1) whether military sexual trauma was associated with the presence of past-week suicidal ideation among 354 Veterans in VHA (310 men, 44 women); (2) whether gender moderated the association between military sexual trauma and suicidal ideation. Information regarding military sexual trauma, suicidal ideation, suicide attempt, and psychiatric diagnoses was obtained from self-report instruments and medical records. Adjusting for age, gender, combat, posttraumatic stress disorder, depressive disorders, negative affect, and lifetime suicide attempt, Veterans with military sexual trauma were significantly more likely to report suicidal ideation, compared to Veterans without military sexual trauma. Furthermore, the association between military sexual trauma and suicidal ideation was stronger for men compared to women. These results contribute to a growing literature identifying military sexual trauma as a risk factor for suicidal thoughts and behaviors among Veterans in VHA care and emphasize the importance of screening for suicidal ideation among survivors of military sexual trauma.
Only the abstract of this article is available for free online.
Osman A, Lamis DA, Bagge CL, Freedenthal S, Barnes SM. The Mindful Attention Awareness Scale: Further Examination of Dimensionality, Reliability, and Concurrent Validity Estimates. J Pers Assess. 2016 Mar-Apr;98(2):189-99. doi:10.1080/00223891.2015.1095761.
We examined the factor structure and psychometric properties of the Mindful Attention Awareness Scale (MAAS) in a sample of 810 undergraduate students. Using common exploratory factor analysis (EFA), we obtained evidence for a 1-factor solution (41.84% common variance). To confirm unidimensionality of the 15-item MAAS, we conducted a 1-factor confirmatory factor analysis (CFA). Results of the EFA and CFA, respectively, provided support for a unidimensional model. Using differential item functioning analysis methods within item response theory modeling (IRT-based DIF), we found that individuals with high and low levels of nonattachment responded similarly to the MAAS items. Following a detailed item analysis, we proposed a 5-item short version of the instrument and present descriptive statistics and composite score reliability for the short and full versions of the MAAS. Finally, correlation analyses showed that scores on the full and short versions of the MAAS were associated with measures assessing related constructs. The 5-item MAAS is as useful as the original MAAS in enhancing our understanding of the mindfulness construct.

Publications - 2015

Barnes SM, Russell LM, Hostetter TA, Forster JE, Devore MD, Brenner LA. Characteristics of traumatic brain injuries sustained among veterans seeking homeless services. J Health Care Poor Underserved. 2015 Feb;26(1):92-105. doi:10.1353/hpu.2015.0010
This hypothesis-generating research describes the characteristics of traumatic brain injuries (TBIs) sustained among 229 Veterans seeking homeless services. Nearly all participants (83%) had sustained at least one TBI prior to their first episode of homelessness. Among participants with a TBI, assaults, transportation-related accidents, and falls were the most common causes of these injuries. Thirty percent of individuals sustained injuries with severity levels that would be expected to be associated with ongoing TBI-related deficits. Forty-three percent of the Veterans sustained at least one brain injury following their first episode of homelessness. Median lifetime number of TBIs was three. The severity of TBIs was similar among Veterans who sustained injuries before or after their first incident of homelessness. Findings suggest that future research should directly examine the potential bi-directional relationship between TBI and homelessness, as well as the impact of TBI-related deficits on Veterans' ability to benefit from homeless services and/or maintain stable housing.
Unfortunately, the full text of this article is behind a pay wall.
Brenner LA, Betthauser LM, Bahraini N, Lusk JL, Terrio H, Scher AI, Schwab KA. Soldiers returning from deployment: A qualitative study regarding exposure, coping, and reintegration. Rehabil Psychol. 2015 Aug;60(3):277-85. doi: 10.1037/rep0000048.
PURPOSE/OBJECTIVE: The purpose of this study was to qualitatively explore exposure to deployment-related physical and/or emotional trauma and associated symptoms among Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) soldiers. Interviews also focused on in-theater- and reintegration-related experiences. RESEARCH METHOD/DESIGN: OEF/OIF soldiers (N = 103) participated in semistructured interviews, and a qualitative descriptive methodology was used to analyze the data. RESULTS: Themes were identified regarding (a) common experiences related to emotional and physical traumas and associated symptoms and strategies for coping and making meaning of experiences and (b) how combat and reintegration experiences affected soldiers' senses of self, relationships with others, and functioning. CONCLUSIONS/IMPLICATIONS: Themes identified support a rethinking of deployment-related mild traumatic brain injury and posttraumatic stress disorder as discrete conditions. Dimensional versus categorical models should be considered. The findings also highlight experiences and potentially meaningful constructs (e.g., moral injury, moral repair) that can be used to inform research and clinical efforts aimed at improving the lives of those who have served. © 2015 APA, all rights reserved).
Unfortunately, the full text of this article is behind a pay wall.
Frank JW, Binswanger IA, Calcaterra SL, Brenner LA, Levy C. Non-medical use of prescription pain medications and increased emergency department utilization: Results of a national survey. Drug Alcohol Depend. 2015 Dec 1;157:150-7. doi: 10.1016/j.drugalcdep.2015.10.027.
BACKGROUND: There are no population-based studies of emergency department (ED) utilization by individuals using prescription pain medications non-medically. We examined whether non-medical use of prescription pain medications was independently associated with increased ED utilization. METHODS: We conducted a retrospective analysis of a nationally representative sample of the non-institutionalized, civilian U.S. population in the National Survey on Drug Use and Health, 2008-2013. We used multivariable logistic regression to examine the association between past year ED utilization and non-medical use of prescription pain medications, defined as use of medications "not prescribed for you or that you took only for the experience or feeling they caused". RESULTS: An estimated 10.5 million adults annually reported past year non-medical use (NMU) of prescription pain medications, and 39%, or 4.1 million adults annually, also reported one or more past year ED visits. After adjustment for sociodemographic and clinical characteristics, adults with past year NMU of prescription pain medications had increased odds of past year ED utilization (adjusted odds ratio 1.32; 95% confidence interval 1.24-1.41). In secondary analyses, individuals with more frequent NMU had increased odds of ED utilization in unadjusted analyses, but this association was attenuated with adjustment for the source of prescription pain medication (i.e., physician, friend/family, other source). CONCLUSIONS: Non-medical use of prescription pain medications is associated with increased ED utilization. Further work is needed to identify the optimal role of ED settings in providing screening, education, and treatment referral for individuals using prescription pain medications non-medically. Published by Elsevier Ireland Ltd.
KEYWORDS: Emergency department; Health services research; Non-medical use; Opioid medications
Unfortunately, the full text of this article is behind a pay wall.
Hoisington AJ, Brenner LA, Kinney KA, Postolache TT, Lowry CA. The microbiome of the built environment and mental health. Microbiome. 2015 Dec 17;3(1):60. doi: 10.1186/s40168-015-0127-0.
The microbiome of the built environment (MoBE) is a relatively new area of study. While some knowledge has been gained regarding impacts of the MoBE on the human microbiome and disease vulnerability, there is little knowledge of the impacts of the MoBE on mental health. Depending on the specific microbial species involved, the transfer of microorganisms from the built environment to occupant's cutaneous or mucosal membranes has the potential to increase or disrupt immunoregulation and/or exaggerate or suppress inflammation. Preclinical evidence highlighting the influence of the microbiota on systemic inflammation supports the assertion that microorganisms, including those originating from the built environment, have the potential to either increase or decrease the risk of inflammation-induced psychiatric conditions and their symptom severity. With advanced understanding of both the ecology of the built environment, and its influence on the human microbiome, it may be possible to develop bioinformed strategies for management of the built environment to promote mental health. Here we present a brief summary of microbiome research in both areas and highlight two interdependencies including the following: (1) effects of the MoBE on the human microbiome and (2) potential opportunities for manipulation of the MoBE in order to improve mental health. In addition, we propose future research directions including strategies for assessment of changes in the microbiome of common areas of built environments shared by multiple human occupants, and associated cohort-level changes in the mental health of those who spend time in the buildings. Overall, our understanding of the fields of both the MoBE and influence of host-associated microorganisms on mental health are advancing at a rapid pace and, if linked, could offer considerable benefit to health and wellness.
The full text of this article is available for free online.
Monteith LL, Pease JL, Forster JE, Homaifar BY, Bahraini NH. Values as Moderators of the Association between Interpersonal-Psychological Constructs and Suicidal Ideation among Veterans. Arch Suicide Res. 2015 Oct-Dec;19(4):422-34. doi: 10.1080/13811118.2015.1004486.
This study examined whether valuing relationships, achievement, and security moderated the association between interpersonal-psychological constructs (Joiner, 2005 ) and suicidal ideation (SI). A total of 122 veterans completed the Interpersonal Needs Questionnaire, Survey of Life Principles, and Beck Scale for Suicide Ideation. Valuing relationships moderated the association between thwarted belongingness and SI. Specifically, thwarted belongingness predicted SI among veterans who reported moderate and high, but not low, levels of valuing relationships. The estimated impact of perceived burdensomeness on SI was stronger at higher levels of valuing relationships, but only approached statistical significance. Valuing achievement and security did not moderate the association between perceived burdensomeness and SI. Future research should continue to examine specific values as they relate to interpersonal-psychological constructs and suicidal behavior.
KEYWORDS: interpersonal-psychological theory of suicide, suicidal ideation; thwarted belongingness; values; veterans
Unfortunately, the full text of this article is behind a pay wall.
Okusaga O, Duncan E, Langenberg P, Brundin L, Fuchs D, Groer MW, Giegling I, Stearns-Yoder KA, Hartmann AM, Konte B, Friedl M, Brenner LA, Lowry CA, Rujescu D, Postolache TT. Combined Toxoplasma gondii seropositivity and high blood kynurenine - Linked with nonfatal suicidal self-directed violence in patients with schizophrenia. J Psychiatr Res. 2016 Jan;72:74-81. doi:10.1016/j.jpsychires.2015.10.002
Toxoplasma gondii (T. gondii) chronic infection and elevated kynurenine (KYN) levels have been individually associated with non-fatal suicidal self-directed violence (NF-SSDV). We aimed to test the hypothesis that the association between T. gondii seropositivity and history of NF-SSDV would be stronger in schizophrenia patients with high plasma KYN levels than in those with lower KYN levels. We measured anti-T. gondii IgG antibodies and plasma KYN in 950 patients with schizophrenia, and used logistic regression to evaluate the relationship between NF-SSDV and KYN in patients who were either seropositive or seronegative for T. gondii. For those with KYN levels in the upper 25th percentile, the unadjusted odds ratio for the association between NF-SSDV history and KYN in T. gondii seropositive patients was 1.63 (95% CI 1.01 to 2.66), p = 0.048; the adjusted odds ratio was 1.95 (95% CI 1.15 to 3.30), p = 0.014. Plasma KYN was not associated with a history of NF-SSDV in T. gondii seronegative patients. The results suggest that T. gondii and KYN may have a nonlinear cumulative effect on the risk of NF-SSDV among those with schizophrenia. If confirmed by future longitudinal studies, this result is expected to have both theoretical and clinical implications for the prevention and treatment of suicidal behavior. Published by Elsevier Ltd.
KEYWORDS: Kynurenine; Non-fatal suicidal self-directed violence; Schizophrenia; Toxoplasma gondii
Unfortunately, the full text of this article is behind a pay wall.
Raheja UK, Fuchs D, Giegling I, Brenner LA, Rovner SF, Mohyuddin I, Weghuber D, Mangge H, Rujescu D, Postolache TT. In psychiatrically healthy individuals, overweight women but not men have lower tryptophan levels. Pteridines. 2015 Jun;26(2):79-84. PubMed PMID: 26251562; PubMed Central PMCID: PMC4523236.
Gender differences in tryptophan (TRP) breakdown in obese individuals have been previously reported. This could be both contributory to, as well as a consequence of, gender differences in mood changes among obese people. To exclude the potential effect of depression on TRP breakdown and its levels in obesity, we replicated analyses in psychiatrically healthy individuals. In 1000 participants, plasma kynurenine (KYN), TRP, and the KYN/TRP ratio were compared between overweight/obese and normal-weight individuals using analysis of covariance, with adjustment for age and gender. Bivariate post hoc tests were also conducted. There were no significant relationships between KYN, TRP, or the KYN/TRP ratio and overall overweight/obese status. However, a significant gender by weight category interaction was identified for TRP only, with overweight/obese women having lower TRP than overweight/obese men (p = 0.02). No gender differences in TRP were found in non-obese participants. Our study in psychiatrically healthy individuals suggested that lower TRP levels in obese women were not secondary to depression, strengthening the possibility that TRP levels could mediate depression in vulnerable women. Thus experimental manipulations of TRP levels could be used to advance theoretical knowledge, prevention, and clinical control of depression in obese women.
KEYWORDS: gender differences; obesity; tryptophan; women
The full text of this article is available for free online.
Signoracci GM, Stearns-Yoder KA, Holliman BD, Huggins JA, Janoff EN, Brenner LA. Listening to Our Patients: Learning About Suicide Risk and Protective Factors From Veterans With HIV/AIDS. J Holist Nurs. 2015 Nov 16. pii: 0898010115610688.
PURPOSE: We sought to gather perspectives of veterans with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) regarding suicide risk factors, warning signs, and protective factors. We also aimed to modify an existing Veterans Health Administration tool, the Suicide Risk Assessment Guide Pocket Card, for HIV/AIDS provider use. METHODS: Twenty male veterans participated in audio-recorded semistructured interviews that were transcribed and coded for themes. FINDINGS: Veterans highlighted personally relevant psychosocial stressors (i.e., poverty, social isolation and loneliness, and physical health). Although the concept of warning signs did not seem salient to participants, they named indicators of elevated imminent risk for self-directed violence (i.e., "relapse," "not take'n medications," and "miss'n appointments") and few protective factors. No themes emerged regarding recommended pocket card changes. CONCLUSIONS: This sample of veterans identified self-directed violence risks noted in the general population and others with HIV/AIDS, as well as proximal events associated with increased risk. Care providers are encouraged to explore the relevance of noted imminent and persistent indicators of increased risk with veterans seeking care. © The Author(s) 2015.
KEYWORDS: HIV/AIDS; psychosocial/mental health; veterans
The full text of this article is available for free online.

Publications - 2014

Anestis MD, Soberay KA, Gutierrez PM, Hernández TD, Joiner TE. Reconsidering the Link Between Impulsivity and Suicidal Behavior. Pers Soc Psychol Rev. 2014 Jun 26.
It is widely accepted that suicidal behavior often occurs with little planning. We propose, however, that suicidal behavior is rarely if ever impulsive-that it is too frightening and physically distressing to engage in without forethought-and that suicidal behavior in impulsive individuals is accounted for by painful and fearsome behaviors capable of enhancing their capacity for suicide. We conducted a meta-analysis of the association between trait impulsivity and suicidal behavior and a critical review of research considering the impulsiveness of specific suicide attempts. Meta-analytic results suggest the relationship between trait impulsivity and suicidal behavior is small. Furthermore, studies examining a mediating role of painful and provocative behaviors have uniformly supported our model. Results from our review suggest that researchers have been unable to adequately measure impulsivity of attempts and that measures sensitive to episodic planning must be developed to further our understanding of this phenomenon. © 2014 by the Society for Personality and Social Psychology, Inc.
Keywords: Suicide
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Arciniegas DB, Wortzel HS. Emotional and Behavioral Dyscontrol After Traumatic Brain Injury. Psychiatr Clin North Am. 2014 Mar;37(1):31-53.
Emotional and behavioral dyscontrol are relatively common neuropsychiatric sequelae of traumatic brain injury and present substantial challenges to recovery and community participation. Among the most problematic and functionally disruptive of these types of behaviors are pathologic laughing and crying, affective lability, irritability, disinhibition, and aggression. Managing these problems effectively requires an understanding of their phenomenology, epidemiology, and clinical evaluation. This article reviews these issues and provides clinicians with brief and practical suggestions for the management of emotional and behavioral dyscontrol. Published by Elsevier Inc.
Keywords: Traumatic Brain Injury (TBI)
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Bahraini, N. H., Bossarte, R., Brenner, L.A., Dobscha, S., Oslin, D., & Wendleton, L. (in press). Identifying Veterans at Risk For Suicidal Behavior. Report for VA Central Office Patient Services Leadership, 2014.
Keywords: Suicide
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Bahraini NH, Breshears RE, Hernández TD, Schneider AL, Forster JE, Brenner LA. Traumatic Brain Injury and Posttraumatic Stress Disorder. Psychiatr Clin North Am. 2014 Mar;37(1):55-75.
Given the upsurge of research in posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI), much of which has focused on military samples who served in Iraq and Afghanistan, the purpose of this article is to review the literature published after September 11th, 2001 that addresses the epidemiology, pathophysiology, evaluation, and treatment of PTSD in the context of TBI. Published by Elsevier Inc.
PubMed Keywords: Brain injury, Evaluation, Imaging, Pathophysiology, Posttraumatic stress, Treatment
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Berger, A.M., Desaulniers, G., Matthews, E. E., Otte, J., & Page, M. (in press). Sleep-Wake Disturbances. In M. Irwin, & L. Johnson (Eds.), Putting evidence into practice. Pittsburg, PA: Oncology Nursing Society.
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Betz ME, Jones J, Genco E, Carr DB, Diguiseppi C, Haukoos JS, Lowenstein SR, Schwartz R. Perspectives on Tiered Older Driver Assessment in Primary Care Settings. Gerontologist. 2014 May 2.
Purpose of the Study: Widespread screening of older drivers, with in-depth evaluation only of those who screen positive ("tiered assessment"), might efficiently balance driver safety and mobility. To inform program development, we sought to examine the perspectives of older drivers and clinicians on the concept of tiered assessment in primary care settings. DESIGN AND METHODS: Iterative focus groups and interviews with 33 community-dwelling current drivers aged ≥65 years and 8 primary care providers. We used inductive and deductive theme analysis to explore driver and clinician perspectives and to identify barriers and facilitators to establishing a tiered older driver assessment program in primary care settings. RESULTS: Four dominant themes emerged. Two themes addressed the overall concept: (a) support for the concept of tiered older driver assessment and (b) concerns about the consequences of older driver assessment and how these could affect program viability. Two themes addressed screening: (c) tension inherent in using a generalized approach to the highly individualized issue of driving and (d) logistical considerations for screening in primary care settings. IMPLICATIONS: Standardized older driver screening and referral might improve clinician-driver communication, but screening should occur in a context that includes personalized mobility counseling.
PubMed Keywords: Clinical practice; Driving; Physician-patient communication/relationships; Preventive medicine/care/services; Qualitative research methods
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Bogdanova OV, Abdullah O, Kanekar S, Bogdanov VB, Prescot AP, Renshaw PF. Neurochemical alterations in frontal cortex of the rat after one week of hypobaric hypoxia. Behav Brain Res. 2014 Apr 15;263:203-9.
Residing at high altitude may lead to reduced blood oxygen saturation in the brain and altered metabolism in frontal cortical brain areas, probably due to chronic hypobaric hypoxia. These changes may underlie the increased rates of depression and suicidal behavior that have been associated with life at higher altitudes. To test the hypothesis that hypobaric hypoxia is responsible for development of mood disorders due to alterations in neurochemistry, we assessed depression-like behavior in parallel to levels of brain metabolites in rats housed at simulated altitude. 32 female Sprague Dawley rats were housed either in a hypobaric hypoxia chamber at 10,000ft of simulated altitude for 1 week or at local conditions (4500ft of elevation in Salt Lake City, Utah). Depression-like behavior was assessed using the forced swim test (FST) and levels of neurometabolites were estimated by in vivo proton magnetic resonance spectroscopy in the frontal cortex, the striatum and the hippocampus at baseline and after a week of exposure to hypobaric hypoxia. After hypoxia exposure the animals demonstrated increased immobility behavior and shortened latency to immobility in the FST. Elevated ratios of myo-inositol, glutamate, and the sum of myo-inositol and glycine to total creatine were observed in the frontal cortex of hypoxia treated rats. A decrease in the ratio of alanine to total creatine was also noted. This study shows that hypoxia induced alterations in frontal lobe brain metabolites, aggravated depression-like behavior and might be a factor in increased rates of psychiatric disorders observed in populations living at high altitudes. Copyright © 2014 Elsevier B.V. All rights reserved.
PubMed Keywords: Behavior, Depression, Hypobaric hypoxia, Proton magnetic resonance spectroscopy
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Han DH, Kim BN, Cheong JH, Kang KD, Renshaw PF. Anxiety and Attention Shifting in Professional Baseball Players. Int J Sports Med. 2014 Feb 19.
Based on the work of both Eysenck and Nideffer, we hypothesized that higher ranking players (HRP) would have lower competitive anxiety and more flexible attention-shifting, compared to lower ranking players (LRP). In addition, different patterns of attention (low anxiety and flexible attention) would be represented by a different pattern of brain activity within the temporal lobe and dorsolateral prefrontal cortex. In accordance with the rookie draft ranking, the players were classified into 2 groups: HRP (top 30% of those selected in the draft) vs. LRP (bottom 30% of those selected in the draft). For assessment of executive function, a computerized version of the Wisconsin Card-sorting Test (WCST) was used. Brain activity was assessed using 1.5-Tesla functional magnetic resonance imaging. In response to scenes depicting baseball errors, HRP showed increased activation in the left cingulate cortex and decreased activation in right middle temporal gyrus, compared to LRP. In response to the simplified WCST in the scanner, HRP showed increased activation in left superior frontal cortex (DLPFC), compared to LRP. The present results suggest that HRP may demonstrate elevated cingulate activation and lower temporal cortex activation in response to scenes depicting baseball errors. © Georg Thieme Verlag KG Stuttgart · New York.
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Homaifar, B. Y. (2014). The relationship of executive functioning to negative and positive impacts of stress. In K. Bennett (Ed.), Executive Functioning: Role in Early Learning Processes, Impairments in Neurological Disorders and Impact of Cognitive Behavior Therapy. (pp. 199-210). New York, NY: Nova Science Publishers, Inc.
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Homaifar, B. Y., Billera, M., Barnes, S. M., Bahraini, N. H., & Brenner, L. (in press). Understanding Traumatic Brain Injury and Suicide Through the Lens of Executive Dysfunction. In G. Sullivan, L. James, & B. Bongar (Eds.), The Oxford Handbook of Suicide in Military and Veteran Populations. New York, NY: Oxford University Press.
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Homaifar, B. Y., Olson-Madden, J., Matarazzo, B. E., & Brenner, L. (in press). Assessment of Mood Disorders and Suicidal Thoughts and Behavior in Veterans. In S. Bush (Ed.), Psychological Assessment of Veterans. New York, NY: Oxford University Press.
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Huber RS, Coon H, Kim N, Renshaw PF, Kondo DG. Altitude is a risk factor for completed suicide in bipolar disorder. Med Hypotheses. 2014 Mar;82(3):377-81.
Bipolar disorder (BD) is a severe brain disease that is associated with a significant risk for suicide. Recent studies indicate that altitude of residence significantly affects overall rate of completed suicide, and is associated with a higher incidence of depressive symptoms. Bipolar disorder has shown to be linked to mitochondrial dysfunction that may increase the severity of episodes. The present study used existing data sets to explore the hypothesis that altitude has a greater effect of suicide in BD, compared with other mental illnesses. The study utilized data extracted from the National Violent Death Reporting System (NVDRS), a surveillance system designed by the Centers for Disease Control and Prevention (CDC) National Center for Injury Prevention and Control (NCIPC). Data were available for 16 states for the years 2005-2008, representing a total of 35,725 completed suicides in 922 U.S. counties. Random coefficient and logistic regression models in the SAS PROC MIXED procedure were used to estimate the effect of altitude on decedent's mental health diagnosis. Altitude was a significant, independent predictor of the altitude at which suicides occurred (F=8.28, p=0.004 and Wald chi-square=21.67, p<0.0001). Least squares means of altitude, independent of other variables, indicated that individuals with BD committed suicide at the greatest mean altitude. Moreover, the mean altitude at which suicides occurred in BD was significantly higher than in decedents whose mental health diagnosis was major depressive disorder (MDD), schizophrenia, or anxiety disorder. Identifying diagnosis-specific risk factors such as altitude may aid suicide prevention efforts, and provide important information for improving the clinical management of BD. Copyright © 2014 Elsevier Ltd. All rights reserved.
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Kondo DG, Hellem TL, Shi XF, Sung YH, Prescot AP, Kim TS, Huber RS, Forrest LN, Renshaw PF. A Review of MR Spectroscopy Studies of Pediatric Bipolar Disorder. AJNR Am J Neuroradiol. 2014 Feb 20.
Pediatric bipolar disorder is a severe mental illness whose pathophysiology is poorly understood and for which there is an urgent need for improved diagnosis and treatment. MR spectroscopy is a neuroimaging method capable of in vivo measurement of neurochemicals relevant to bipolar disorder neurobiology. MR spectroscopy studies of adult bipolar disorder provide consistent evidence for alterations in the glutamate system and mitochondrial function. In bipolar disorder, these 2 phenomena may be linked because 85% of glucose in the brain is consumed by glutamatergic neurotransmission and the conversion of glutamate to glutamine. The purpose of this article is to review the MR spectroscopic imaging literature in pediatric bipolar disorder, at-risk samples, and severe mood dysregulation, with a focus on the published findings that are relevant to glutamatergic and mitochondrial functioning. Potential directions for future MR spectroscopy studies of the glutamate system and mitochondrial dysfunction in pediatric bipolar disorder are discussed.
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Matarazzo BB, Barnes SM, Pease JL, Russell LM, Hanson JE, Soberay KA, Gutierrez PM. Suicide Risk among Lesbian, Gay, Bisexual, and Transgender Military Personnel and Veterans: What Does the Literature Tell Us? Suicide Life Threat Behav. 2014 Feb 3.
Research suggests that both the military and veteran and the lesbian, gay, bisexual, and transgender (LGBT) populations may be at increased risk for suicide. A literature review was conducted to identify research related to suicide risk in the LGBT military and veteran populations. Despite the paucity of research directly addressing this issue, themes are discussed evident in the literature on LGBT identity and suicide risk as well as LGBT military service members and veterans. Factors such as social support and victimization appear to be particularly relevant. Suggestions are made with respect to future research that is needed on this very important and timely topic. © Published 2014. This article is a U.S. Government work and is in the public domain in the USA.
Keywords: Suicide Prevention
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Matarazzo BB, Hoffberg AS, Clemans TA, Signoracci GM, Simpson GK, Brenner LA. Cross-cultural adaptation of the Window to Hope: A psychological intervention to reduce hopelessness among US Veterans with traumatic brain injury. Brain Inj. 2014 Jun 19:1-10.
Abstract Primary objective: To conduct a cross-cultural adaptation of Window to Hope (WtoH), a treatment to reduce hopelessness after traumatic brain injury (TBI), from the Australian civilian context to that of US Veterans. Research design: Three-stage mixed-methods approach. Methods: Stage 1: Consensus conference with stakeholders to revise the manual. Stage 2: Pilot study of the revised manual with US Veterans to examine acceptability, feasibility and fidelity. Stage 3: Review of results with consensus conference attendees and further revisions. Results: Stage 1: Conference attendees reached 100% consensus regarding changes made to the manual. Stage 2: Qualitative results yielded themes that suggest that participants benefitted from the intervention and that multiple factors contributed to successful implementation (Narrative Evaluation of Intervention Interview, User Feedback Survey-Modified, Post-Treatment Interviews). Therapists achieved 100% treatment fidelity. Quantitative results from the Client Satisfaction Questionnaire-8 suggest that the intervention was acceptable. Stage 3: The culturally adapted manual was finalized. Conclusions: Results of this study suggest that the revised WtoH manual is acceptable and feasible. US therapists exhibited adherence to the protocol. The three-stage methodology was successfully employed to cross-culturally adapt an intervention that is well-suited for a Phase II randomized controlled trial among US military Veterans.
Pubmed Keywords: Cognitive behaviour therapy; mental health; suicide prevention
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Matarazzo BB, Homaifar BY, Wortzel HS. Therapeutic risk management of the suicidal patient: safety planning. J Psychiatr Pract. 2014 May;20(3):220-4.
This column is the fourth in a series describing a model for therapeutic risk management of the suicidal patient. Previous columns presented an overview of the therapeutic risk management model, provided recommendations for how to augment risk assessment using structured assessments, and discussed the importance of risk stratification in terms of both severity and temporality. This final column in the series discusses the safety planning intervention as a critical component of therapeutic risk management of suicide risk. We first present concerns related to the relatively common practice of using no-suicide contracts to manage risk. We then present the safety planning intervention as an alternative approach and provide recommendations for how to use this innovative strategy to therapeutically mitigate risk in the suicidal patient. (Journal of Psychiatric Practice 2014;20:220-224).
Keywords: Suicide Prevention
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Matthews EE, Berger AM, Schmiege SJ, Cook PF, McCarthy MS, Moore CM, Aloia MS. Cognitive behavioral therapy for insomnia outcomes in women after primary breast cancer treatment: a randomized, controlled trial. Oncol Nurs Forum. 2014 May;41(3):241-53.
PURPOSE/OBJECTIVES: To examine the effect of cognitive-behavioral therapy for insomnia (CBTI) on sleep improvement, daytime symptoms, and quality of life (QOL) in breast cancer survivors (BCSs) after cancer treatment. DESIGN: A prospective, longitudinal, randomized, controlled trial. SETTING: Oncology clinics, breast cancer support groups, and communities in Colorado. SAMPLE: 56 middle-aged BCSs with chronic insomnia. METHODS: Women were randomly assigned to CBTI or behavioral placebo treatment (BPT) and completed measures of sleep, QOL, functioning, fatigue, and mood at baseline, postintervention, and at three- and six-month follow-ups. MAIN RESEARCH VARIABLES: Sleep outcomes (e.g., sleep efficiency, sleep latency, total sleep time, wake after sleep onset, number of nightly awakenings); secondary variables included sleep medication use, insomnia severity, QOL, physical function, cognitive function, fatigue, depression, anxiety, and sleep attitudes or knowledge. FINDINGS: Sleep efficiency and latency improved more in the CBTI group than the BPT group; this difference was maintained during follow-up. Women in the CBTI group had less subjective insomnia, greater improvements in physical and cognitive functioning, positive sleep attitudes, and increased sleep hygiene knowledge. No group differences in improvement were noted relative to QOL, fatigue, or mood. CONCLUSIONS: Nurse-delivered CBTI appears to be beneficial for BCSs' sleep latency/efficiency, insomnia severity, functioning, sleep knowledge, and attitudes more than active placebo, with sustained benefit over time. IMPLICATIONS FOR NURSING: Oncology nurses are in a unique position to identify insomnia in cancer survivors. When sleep disturbances become chronic, nurses need to make recommendations and referrals.
Keywords: Sleep
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Nadorff MR, Anestis MD, Nazem S, Claire Harris H, Samuel Winer E. Sleep disorders and the interpersonal-psychological theory of suicide: independent pathways to suicidality? J Affect Disord. 2014 Jan;152-154:505-12.
BACKGROUND: Although sleep disorders are a risk factor for suicidal behavior little research has examined why sleep disorders confer suicide risk. The present study examined the relation between two sleep disorders, insomnia symptoms and nightmares, and suicide risk in the context of Joiner's interpersonal-psychological theory of suicide (IPTS). METHODS: The present study utilized two large samples (N=747 and 604) recruited from two large public universities in the Southeast. Both studies included measures of insomnia symptoms, nightmares, depressive symptoms, and prior suicide attempts. In addition, study one contained a measure of suicide risk. RESULTS: In study 1, the relations between insomnia symptoms and both suicide risk and prior attempts were not significant after controlling for the IPTS. However, nightmares were related to both suicide risk and suicide attempts independent of the IPTS. Furthermore, nightmares nearly missed significance in the prediction of suicide risk (p=0.054) and significantly predicted suicide attempts even after controlling for depressive symptoms. In study 2, both insomnia and nightmares were found to be significantly associated with prior suicide attempts after controlling for the IPTS and depressive symptoms. LIMITATIONS: The study is limited by its use of a college sample and cross-sectional design. CONCLUSIONS: These studies suggest that the IPTS may not explain the relation between sleep problems and suicidality. More research is needed to understand the mechanism by which sleep disorders confer suicide risk, which is clinically relevant as it may inform specific interventions to reduce the adverse effects of sleep disorders. © 2013 Published by Elsevier B.V.
PubMed Keywords: Depression, Insomnia symptoms, Interpersonal–psychological theory of suicide, Nightmares, Suicide risk
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Olson-Madden JH, Homaifar BY, Hostetter T, Matarazzo BB, Huggins J, Forster JE, Schneider AL, Nagamoto HT, Corrigan JD, Brenner LA. Validating the Traumatic Brain Injury-4 (TBI-4) Screening Measure for Veterans Seeking Mental Health Treatment with Psychiatric Inpatient and Outpatient Service Utilization Data. Arch Phys Med Rehabil. 2014 Jan 27.
OBJECTIVE: To determine whether a positive screen on the Traumatic Brain Injury-4 (TBI-4) can identify Veterans who utilize more inpatient and outpatient mental health services. Two criteria to identify a positive screen were evaluated. DESIGN: Validation cohort. SETTING: Veterans Affairs Medical Center. PARTICIPANTS: Individual seeking Veterans Health Administration mental health services (N=1,493). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: One year of inpatient and outpatient mental health utilization data following the TBI-4 screen date. RESULTS: In the year post-mental health intake, those who answered positively to any of the four TBI-4 screening questions (Criterion 1) or Question 2 (Criterion 2; ever being "knocked out") had significantly more psychiatric hospitalizations compared to those who met neither criterion. Those who were positive by Criterion 2 also had significantly fewer outpatient mental health contacts. CONCLUSIONS: Veterans screening positive for history of TBI on the TBI-4 had more hospital stays in the year post-mental health intake. Those who reported having been "knocked out", also had fewer outpatient mental health visits. These findings may suggest an overall relationship in this population between greater needs for mental health care and likelihood of prior injury. For those with a history of loss of consciousness, the reduced use of outpatient care may reflect greater problems engaging in treatment or with preventive aspects of the healthcare system, when they are not in crisis. Using a screener such as the TBI-4 could facilitate identification of Veterans who might benefit from targeted and intensive outpatient interventions to avoid frequent inpatient psychiatric hospitalization. Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.
PubMed Keywords: (CDW), (CPT), (TBI), (TBI-4), (TBI-ID), (VAMC), (VHA), Corporate Data Warehouse, Current Procedural Terminology, Traumatic Brian Injury-Identification, Traumatic brain injury, Veterans Administration Medical Center, Veterans Health Administration, hospitalization, mental health, the Traumatic Brain Injury-4, traumatic brain injury, utilization
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O'Neil ME, Carlson KF, Storzbach D, Brenner LA, Freeman M, Quiñones AR, Motu'apuaka M, Kansagara D. Factors Associated with Mild Traumatic Brain Injury in Veterans and Military Personnel: A Systematic Review. J Int Neuropsychol Soc. 2014 Feb 5:1-13.
A history of mild traumatic brain injury (mTBI) is common among military members who served in Operations Enduring Freedom, Iraqi Freedom, and New Dawn (OEF/OIF/OND). We completed a systematic review to describe the cognitive, mental health, physical health, functional, social, and cost consequences of mTBI in Veteran and military personnel. Of 2668 reviewed abstracts, the 31 included studies provided very low strength evidence for the questions of interest. Cognitive, physical, and mental health symptoms were commonly reported by Veterans/military members with a history of mTBI. On average, these symptoms were not significantly more common in those with a history of mTBI than in those without, although a lack of significant mean differences does not preclude the possibility that some individuals could experience substantial effects related to mTBI history. Evidence of potential risk or protective factors moderating mTBI outcomes was unclear. Although the overall strength of evidence is very low due to methodological limitations of included studies, our findings are consistent with civilian studies. Appropriate re-integration services are needed to address common comorbid conditions, such as treatment for post-traumatic stress disorder, substance use disorders, headaches, and other difficulties that Veterans and members of the military may experience after deployment regardless of mTBI history. (JINS, 2014, 20, 1-13).
Keywords: Suicide Prevention
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Osman A, Lamis DA, Freedenthal S, Gutierrez PM, McNaughton-Cassill M. The multidimensional scale of perceived social support: analyses of internal reliability, measurement invariance, and correlates across gender. J Pers Assess. 2014;96(1):103-12.
In this study, we examined estimates of internal consistency reliability, measurement invariance, and differential correlates of the Multidimensional Scale of Perceived Social Support (MSPSS; Zimet, Dahlem, Zimet, & Farley, 1988) in samples of undergraduate men (n = 270) and women (n = 340). The MSPSS is designed to assess 3 sources of perceived social support: family, friends, and significant others. The participants ranged in age from 18 to 24 years (M(age) = 19.60, SD = 1.4 years). First, composite scale reliability and coefficient omega methods provided adequate estimates of internal consistency reliability for the original MSPSS total and subscale scores. Second, results of multiple-groups invariance confirmatory factor analysis provided support for configural and metric invariance. Partial measurement invariance was attained for scalar and strict measurement invariance across men and women. Additionally, given the high correlations among the first-order factors, we conducted multiple-groups bifactor item response theory (bifactor-IRT) analysis to evaluate further the performances of the individual MSPSS items across gender. Support for the bifactor model was strong. Third, we conducted a series of simultaneous regression analyses to identify potential correlates of the social support construct for women and men.
Keywords: Suicide Prevention
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Vanderploeg RD, Nazem S, Brenner LA, Belanger HG, Donnell AJ, Scott SG. Suicidal Ideation among Florida National Guard Members: Combat Deployment and Non-Deployment Risk and Protective Factors. Arch Suicide Res. 2014 Dec 17. [Epub ahead of print]
Objectives: This study examined relationships among risk/protective factors and suicidal ideation (SI) in deployed and non-deployed National Guard members, particularly examining for possible differential effects of deployment on SI. Methods: 3,098 Florida National Guard members completed an anonymous online survey that assessed variables associated with SI including demographics, current psychiatric diagnoses, and pre, during, and post-deployment experiences. Results: Those deployed had significantly higher rates of SI (5.5%) than those not deployed (3.0%; p < .001). In multivariate analyses, among those not deployed, SI was significantly associated with major depressive disorder (p <.001), posttraumatic stress disorder (PTSD) (p <.001), prior psychological trauma (p <.01), and heavy/hazardous alcohol consumption (p < .05). In contrast, in the deployed, only PTSD (p <.001) and deployment-related mild traumatic brain injury (p < .05) were independently associated with SI. Conclusions: Risk and protective factors differed by deployment status in National Guard members suggesting the possible need for cohort-specific treatment targets to minimize SI.
Keywords: PTSD; blast injury; deployment; mental disorders; military personnel; suicidal ideation; traumatic brain injury; suicide prevention
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Walter KH, Dickstein BD, Barnes SM, Chard KM. Comparing Effectiveness of CPT to CPT-C Among U.S. Veterans in an Interdisciplinary Residential PTSD/TBI Treatment Program. J Trauma Stress. 2014 Aug;27(4):438-45.
Cognitive processing therapy (CPT) is a leading cognitive-behavioral treatment for posttraumatic stress disorder (PTSD) and a front-line intervention according to the U.S. Department of Veterans Affairs treatment guidelines. The original CPT protocol entails the creation of a written trauma account and use of cognitive therapy. Cognitive processing therapy-cognitive therapy only (CPT-C) does not involve a written account and in a previous study resulted in faster symptom improvement and fewer dropouts than standard CPT. This study sought to replicate these findings by comparing the effectiveness of CPT to CPT-C in a sample of 86 U.S. male veterans receiving treatment in a PTSD residential program for individuals with a history of traumatic brain injury. CPT and CPT-C were delivered in a combined individual and group format as part of a comprehensive, interdisciplinary treatment program. Outcomes were self- and clinician-reported PTSD and self-reported depression symptoms. Multilevel analysis revealed no significant difference for PTSD symptoms, but did show a greater decrease in depression at posttreatment (d = 0.63) for those receiving CPT. When an experiment-wise α correction was applied, this effect did not remain significant. Published 2014. This article is a US Government work and is in the public domain in the USA.
Keywords: TBI, PTSD
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Wortzel HS, Homaifar B, Matarazzo B, Brenner LA. Therapeutic risk management of the suicidal patient: stratifying risk in terms of severity and temporality. J Psychiatr Pract. 2014 Jan;20(1):63-7.
This column is the third in a series describing a model for therapeutic risk management of the suicidal patient. In the preceding column, we described augmenting clinical suicide risk assessment with structured instruments. In this column, we describe how clinicians can use the totality of available clinical data to offer a two-dimensional risk stratification that qualifies risk in terms of both severity and temporality. By offering two separate designations that reflect severity for both acute and chronic risk, conceptualizing and communicating a patient's risk for suicide is accomplished in a more nuanced way, providing the level of detail necessary when working with high risk individuals, especially those struggling with chronic suicidal ideation. Formulations reflecting suicide risk need to be accurate and facilitate good clinical decision-making in order to optimally balance the principles of autonomy, non-maleficence, and beneficence. Stratifying risk in terms of both severity and temporality helps identify situations in which involuntary hospitalization is warranted, while also helping to minimize unnecessary admissions. Hence, two-dimensional risk stratification that addresses both acute and chronic risk for suicide is an essential component of therapeutic risk management of the suicidal patient.
Keywords: Suicide Prevention
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Publications 2013

Allen, M. H., Abar, B. W., McCormick, M., Barnes, D. H., Haukoos, J., Garmel, G. M., & Bourdreaux, E. D. (2013). Screening for suicidal ideation and attempts among emergency department medical patients: Instrument and results from the Psychiatric Emergency Research Collaboration. Suicide and Life-Threatening Behavior, 43, 313-323.
Joint Commission National Patient Safety Goal 15 calls for organizations "to identify patients at risk for suicide." Overt suicidal behavior accounts for 0.6% of emergency department (ED) visits, but incidental suicidal ideation is found in 3%-11.6%. This is the first multicenter study of suicide screening in EDs. Of 2,243 patients in six diverse emergency settings, 1,068 (47.7%) were screened with a brief instrument. Depression was endorsed by 369 (34.5%); passive suicidal ideation by 79 (7.3%); and active suicidal ideation by 24 (2.3%). One hundred thirty-seven (12.8%) reported prior attempts, including 35 (3.3%) with current suicidal ideation. Almost half of those with current ideation had a prior attempt (43.8%) versus those without current ideation, 10.3%, χ2 (1) = 75.59, p < .001. Twenty cases (25%) were admitted to medical services, but only 10 (12.5%) received mental health assessment; none were admitted directly to a psychiatry service. The prevalence of suicidal ideation here is similar to previous studies but the frequency of prior attempts has not been reported. The 35 cases with current ideation and prior attempt are at risk. As they did not present psychiatrically, they would likely have gone undetected. Despite reporting these cases to clinical staff, few received risk assessment. © 2013 The American Association of Suicidology.
Keywords: Suicide Prevention
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Bahraini N, Brenner LA. Screening for TBI and persistent symptoms provides opportunities for prevention and intervention. J Head Trauma Rehabil. 2013 May-Jun;28(3):223-6.
No abstract available
Keywords: TBI
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Bahraini NH, Devore MD, Monteith LL, Forster JE, Benseng S, Brenner LA. (2013). The role of value importance and success in understanding suicidal ideation among Veterans. Journal of Contextual Behavioral Science. Volume 2, Issues 1–2, 15 April 2013, Pages 31–38
Recent studies highlight the need for increased understanding of risk and protective factors for suicidal thoughts and behaviors among Veterans. Although personal values have been studied in regard to psychological well-being, the degree to which suicidal ideation relates to difficulties successfully living according to one's values or identifying values that are important has yet to be examined in civilian or Veteran populations. One hundred and twenty-two Veterans at an urban medical center completed the Survey of Life Principles (SLP; Ciarrochi & Bailey, 2008), a measure of personal values across several life domains, and the Beck Scale for Suicidal Ideation (BSS; Beck & Steer, 1993). Electronic medical records were reviewed to obtain medical histories. As hypothesized, both the ability to identify values and engage in behavior consistent with values were associated with decreased odds of reporting suicidal ideation, controlling for past suicidal behavior, history of mental health treatment, and psychiatric co-morbidity. Findings suggest that the role of different value dimensions as potential protective factors for suicidal ideation in the Veteran population may warrant further exploration.
Keywords: Suicide Prevention
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Bahraini N, Simpson GK, Brenner LA, Hoffberg AS, Schneider AL. (2013) Suicidal Ideation and Behaviours after Traumatic Brain Injury: A Systematic Review. Brain Impairment / FirstView Article, pp 1-21.
Traumatic brain injury (TBI) is prevalent among many populations and existing data suggest that those with TBI are at increased risk for death by suicide. This systematic review serves as an update to a previous review, with the aim of evaluating the current state of evidence regarding prevalence and risk of suicide deaths, post-TBI suicidal ideation and suicide attempts, and treatments to reduce suicide-related outcomes among TBI survivors. Review procedures followed the PRISMA statement guidelines. In all, 1014 abstracts and 83 full-text articles were reviewed to identify 16 studies meeting inclusion criteria. Risk of bias for individual studies ranged from low to high, and very few studies were designed to examine a priori hypotheses related to suicide outcomes of interest. Overall, findings from this systematic review supported an increased risk of suicide among TBI survivors compared to those with no history of TBI. Evidence pertaining to suicidal thoughts and attempts was less clear, mainly due to heterogeneity of methodological quality across studies. One small randomised controlled trial was identified that targeted suicide prevention in TBI survivors. Further research is needed to identify the prevalence of post-TBI ideation and attempts, and to establish evidence-based suicide prevention practices among TBI survivors.
Keywords: Suicide Prevention, Traumatic Brain Injury (TBI)
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Bogdanov VB, Bogdanova OV, Koulchitsky SV, Chauvel V, Multon S, Makarchuk MY, Brennan KC, Renshaw PF, Schoenen J. Behavior in the open field predicts the number of KCl-induced cortical spreading depressions in rats. Behav Brain Res. 2013 Jan 1;236(1):90-3.
Anxiety disorders are known to be comorbid with migraine, and cortical spreading depression (CSD) is the most likely cause of the migraine aura. To search for possible correlations between susceptibility to CSD and anxiety we used the open field test in male Sprague-Dawley rats chronically treated with the preventive anti-migraine drugs valproate or riboflavin. Animals avoiding the central area of the open field chamber and those with less exploratory activity (i.e. rearing) were considered more anxious. After 4 weeks of treatment CSDs were elicited by application of 1M KCl over the occipital cortex and the number of CSDs occurring over a 2h period was compared to the previously assessed open field behavior. Higher anxiety-like behavior was significantly correlated with a higher frequency of KCl-induced CSDs. In saline-treated animals, fewer rearings were found in animals with more frequent CSDs (R=-1.00). The duration of ambulatory episodes in the open field center correlated negatively with number of CSDs in the valproate group (R=-0.83; p<0.005) and in riboflavin treated group (R=-0.69; p<0.05) as well as total time spent in the open field center in both groups (R=-0.75; p<0.05 and R=-0.58; p<0.1 respectively). These results suggest that anxiety symptoms are associated with susceptibility to CSD and might explain why it can be an aggravating factor in migraine with aura.
Keywords: Depression
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Bogdanova OV, Kanekar S, D'Anci KE, Renshaw PF. Factors influencing behavior in the forced swim test. Physiol Behav. 2013 Jun 13;118:227-39.
The forced swim test (FST) is a behavioral test in rodents which was developed in 1978 by Porsolt and colleagues as a model for predicting the clinical efficacy of antidepressant drugs. A modified version of the FST added the classification of active behaviors into swimming and climbing, in order to facilitate the differentiation between serotonergic and noradrenergic classes of antidepressant drugs. The FST is now widely used in basic research and the pharmaceutical screening of potential antidepressant treatments. It is also one of the most commonly used tests to assess depressive-like behavior in animal models. Despite the simplicity and sensitivity of the FST procedure, important differences even in baseline immobility rates have been reported between different groups, which complicate the comparison of results across studies. In spite of several methodological papers and reviews published on the FST, the need still exists for clarification of factors which can influence the procedure. While most recent reviews have focused on antidepressant effects observed with the FST, this one considers the methodological aspects of the procedure, aiming to summarize issues beyond antidepressant action in the FST. The previously published literature is analyzed for factors which are known to influence animal behavior in the FST. These include biological factors, such as strain, age, body weight, gender and individual differences between animals; influence of preconditioning before the FST: handling, social isolation or enriched environment, food manipulations, various kinds of stress, endocrine manipulations and surgery; schedule and routes of treatment, dosage and type of the drugs as well as experimental design and laboratory environmental effects. Consideration of these factors in planning experiments may result in more consistent FST results. Copyright © 2013 Elsevier Inc. All rights reserved.
Keywords: Neuroimaging
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Boudreaux, E. D., Miller, I., Goldstein, A. B., Sullivan, A. F., Allen, M. H., Manton, A. P., Arias, S. A., & Camargo Jr., C. A. (2013). The Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE): Method and design considerations. Contemporary Clinical Trials, 36, 14-24.
BACKGROUND: Due to the concentration of individuals at-risk for suicide, an emergency department visit represents an opportune time for suicide risk screening and intervention. PURPOSE: The Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) uses a quasi-experimental, interrupted time series design to evaluate whether (1) a practical approach to universally screening ED patients for suicide risk leads to improved detection of suicide risk and (2) a multi-component intervention delivered during and after the ED visit improves suicide-related outcomes. METHODS: This paper summarizes the ED-SAFE's study design and methods within the context of considerations relevant to effectiveness research in suicide prevention and pertinent human participants concerns. 1440 suicidal individuals, from 8 general ED's nationally will be enrolled during three sequential phases of data collection (480 individuals/phase): (1) Treatment as Usual; (2) Universal Screening; and (3) Intervention. Data from the three phases will inform two separate evaluations: Screening Outcome (Phases 1 and 2) and Intervention (Phases 2 and 3). Individuals will be followed for 12months. The primary study outcome is a composite reflecting completed suicide, attempted suicide, aborted or interrupted attempts, and implementation of rescue procedures during an outcome assessment. CONCLUSIONS: While 'classic' randomized control trials (RCT) are typically selected over quasi-experimental designs, ethical and methodological issues may make an RCT a poor fit for complex interventions in an applied setting, such as the ED. ED-SAFE represents an innovative approach to examining the complex public health issue of suicide prevention through a multi-phase, quasi-experimental design embedded in 'real world' clinical settings. Copyright © 2013 Elsevier Inc. All rights reserved.
Keywords: Suicide Prevention
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Bracken BK, Rouse ED, Renshaw PF, Olson DP. T2 relaxation effects on apparent N-acetylaspartate concentration in proton magnetic resonance studies of schizophrenia. Psychiatry Res. 2013 Aug 30;213(2):142-53.
Over the past two decades, many magnetic resonance spectroscopy (MRS) studies reported lower N-acetylaspartate (NAA) in key brain regions of patients with schizophrenia (SZ) compared to healthy subjects. A smaller number of studies report no difference in NAA. Many sources of variance may contribute to these discordant results including heterogeneity of the SZ subject populations and methodological differences such as MRS acquisition parameters, and post-acquisition analytic methods. The current study reviewed proton MRS literature reporting measurements of NAA in SZ with a focus on methodology. Studies which reported lower NAA were significantly more likely to have used longer echo times (TEs), while studies with shorter TEs reported no concentration difference. This suggests that NAA quantitation using MRS was affected by the choice of TE, and that published MRS literature reporting NAA in SZ using a long TE is confounded by apparent differential T2 relaxation effects between SZ and healthy control groups. Future MRS studies should measure T2 relaxation times. This would allow for spectral concentration measurements to be appropriately corrected for these relaxation effects. In addition, as metabolite concentration and T2 relaxation times are completely independent variables, this could offer distinct information about the metabolite of interest. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.
Keywords: Neuroimaging, Psychotic Disorders (schizophrenia, bipolar, SMI, etc)
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Brady RO Jr, McCarthy JM, Prescot AP, Jensen JE, Cooper AJ, Cohen BM, Renshaw PF, Ongür D. Brain gamma-aminobutyric acid (GABA) abnormalities in bipolar disorder. Bipolar Disord. 2013 Jun;15(4):434-9.
OBJECTIVES: Gamma-aminobutyric acid (GABA) abnormalities have been implicated in bipolar disorder. However, due to discrepant studies measuring postmortem, cerebrospinal fluid, plasma, and in vivo brain levels of GABA, the nature of these abnormalities is unclear. Using proton magnetic resonance spectroscopy, we investigated tissue levels of GABA in the anterior cingulate cortex and parieto-occipital cortex of participants with bipolar disorder and healthy controls. METHODS: Fourteen stably medicated euthymic outpatients with bipolar disorder type I (mean age 32.6 years, eight male) and 14 healthy control participants (mean age 36.9 years, 10 male) completed a proton magnetic resonance spectroscopy scan at 4-Tesla after providing informed consent. We collected data from two 16.7-mL voxels using MEGAPRESS, and they were analyzed using LCModel. RESULTS: GABA/creatine ratios were elevated in bipolar disorder participants compared to healthy controls [F(1,21) = 4.4, p = 0.048] in the anterior cingulate cortex (25.1% elevation) and the parieto-occipital cortex (14.6% elevation). Bipolar disorder participants not taking GABA-modulating medications demonstrated greater GABA/creatine elevations than patients taking GABA-modulating medications. CONCLUSIONS: We found higher GABA/creatine levels in euthymic bipolar disorder outpatients compared to healthy controls, and the extent of this elevation may be affected by the use of GABA-modulating medications. Our findings suggest that elevated brain GABA levels in bipolar disorder may be associated with GABAergic dysfunction and that GABA-modulating medications reduce GABA levels in this condition. © 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
Keywords: Brain (Neuroanatomy, Neurocognition, Neurotransmitters, etc), Mood Disorders
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Brennan BP, Jensen JE, Hudson JI, Coit CE, Beaulieu A, Pope HG Jr, Renshaw PF, Cohen BM. A placebo-controlled trial of acetyl-L-carnitine and α-lipoic acid in the treatment of bipolar depression. J Clin Psychopharmacol. 2013 Oct;33(5):627-35.
BACKGROUND: Bipolar disorder may be associated with mitochondrial dysfunction. Therefore, agents that enhance mitochondrial functioning may be efficacious in bipolar disorder. We performed a randomized placebo-controlled trial of the mitochondrial enhancers acetyl-L-carnitine (ALCAR) and α-lipoic acid (ALA) in patients with bipolar depression, and assessed markers of cerebral energy metabolism using phosphorus magnetic resonance spectroscopy. METHODS: We administered ALCAR (1000-3000 mg daily) plus ALA (600-1800 mg daily) or placebo for 12 weeks to 40 patients with bipolar depression and obtained imaging data at baseline, week 1, and week 12 of treatment in 20 patients using phosphorus 3-dimensional chemical-shift imaging at 4 T. Statistical analysis used random effects mixed models. RESULTS: We found no significant difference between ALCAR/ALA and placebo on change from baseline in the Montgomery-Asberg Depression Rating Scale in both the longitudinal (mean difference [95% confidence interval], -1.4 [-6.2 to 3.4], P = 0.58) and last-observation-carried-forward (-3.2 [-7.2 to 0.9], P = 0.12) analyses. ALCAR/ALA treatment significantly reduced phosphocreatine levels in the parieto-occipital cortex at week 12 (P = 0.002). Reduction in whole brain total nucleoside triphosphate levels from baseline to week 1 was associated with reduction in Montgomery-Asberg Depression Rating Scale scores (P = 0.02) in patients treated with ALCAR/ALA. However, this was likely a chance finding attributable to multiple statistical comparisons. CONCLUSIONS: Treatment with ALCAR and ALA at the dose and duration used in this study does not have antidepressant effects in depressed bipolar patients and does not significantly enhance mitochondrial functioning in this patient group.
Keywords: Mood Disorders
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Brenner, L. A., Hoffberg, A. S., Shura, R. D., Bahraini, N., & Wortzel, H. S. (2013). Interventions for mood-related issues post traumatic brain injury: Novel treatments and ongoing limitations of current research. Current Physical Medicine and Rehabilitation Reports, September 2013, Volume 1, Issue 3, pp 143-150
Mood-related issues following traumatic brain injuries (TBI) are highly prevalent and negatively impact psychosocial functioning. Such symptoms are also frequently undertreated. The aim of this publication is to highlight work regarding interventions for the treatment of post-TBI mood issues. Twelve recently published articles were identified (two systematic reviews, one Cochrane protocol, and nine original research studies). Presented manuscripts support both traditional (e.g., psychotherapy) and novel (e.g., exercise) interventions. Despite these scholarly endeavors, definitive findings regarding effective treatments for post-TBI mood disorders remain sparse. Of particular concern was the lack of recent research regarding traditional pharmacological interventions. Further work is required to identify efficacious and effective interventions for members of this high risk population.
Keywords: Traumatic Brain Injury (TBI)
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Brenner LA, Homaifar BY, Olson-Madden JH, Nagamoto HT, Huggins J, Schneider AL, Forster JE, Matarazzo B, Corrigan JD. Prevalence and Screening of Traumatic Brain Injury Among Veterans Seeking Mental Health Services. J Head Trauma Rehabil. 2013 Jan;28(1):21-30.
OBJECTIVES:: To assess the prevalence of traumatic brain injury (TBI) among Veterans seeking mental health services using a 4-item tool, the Traumatic Brain Injury-4 (TBI-4), and to establish the classification accuracy of the TBI-4 using the Ohio State University TBI-Identification Method as the criterion standard. STUDY DESIGN:: Archival and observational data collected from individuals seeking care at a Mountain State VA Medical Center. PARTICIPANTS:: The sample for the archival study was 1810. Three hundred sixteen Veterans completed observational study measures. MAIN MEASURES:: For the archival study, TBI-4 and demographic data extracted from electronic medical records. For the observational study, the Ohio State University TBI-Identification Method and a demographic questionnaire were used. TBI-4 data were also obtained from electronic medical records. RESULTS:: The prevalence of probable TBI among those seeking VA MH treatment was 45%. Sensitivity and specificity of the TBI-4 were 0.74 and 0.56, respectively. Veterans with all levels of TBI severity sought care within this VA mental health setting. CONCLUSIONS:: The prevalence of TBI in this VA mental health treatment population was higher than expected. Additional research is required to assess the clinical utility of screening for TBI among this population of Veterans.
Keywords: Assessment, Suicide Prevention, Traumatic Brain Injury (TBI)
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Bryan CJ, Clemans TA. (2013). Repetitive Traumatic Brain Injury, Psychological Symptoms, and Suicide Risk in a Clinical Sample of Deployed Military Personnel. JAMA Psychiatry. ():1-6.
Importance: Traumatic brain injury (TBI) is believed to be one factor contributing to rising suicide rates among military personnel and veterans. This study investigated the association of cumulative TBIs with suicide risk in a clinical sample of deployed military personnel referred for a TBI evaluation. Objective: To determine whether suicide risk is more frequent and heightened among military personnel with multiple lifetime TBIs than among those with no TBIs or a single TBI. Design: Patients completed standardized self-report measures of depression, posttraumatic stress disorder (PTSD), and suicidal thoughts and behaviors; clinical interview; and physical examination. Group comparisons of symptom scores according to number of lifetime TBIs were made, and generalized regression analyses were used to determine the association of cumulative TBIs with suicide risk. Participants: Patients included 161 military personnel referred for evaluation and treatment of suspected head injury at a military hospital's TBI clinic in Iraq. Main Outcomes and Measures: Behavioral Health Measure depression subscale, PTSD Checklist–Military Version, concussion symptoms, and Suicide Behaviors Questionnaire–Revised. Results: Depression, PTSD, and TBI symptom severity significantly increased with the number of TBIs. An increased incidence of lifetime suicidal thoughts or behaviors was associated with the number of TBIs (no TBIs, 0%; single TBI, 6.9%; and multiple TBIs, 21.7%; P = .009), as was suicidal ideation within the past year (0%, 3.4%, and 12.0%, respectively; P = .04). The number of TBIs was associated with greater suicide risk (β [SE] = .214 [.098]; P = .03) when the effects of depression, PTSD, and TBI symptom severity were controlled for. A significant interaction between depression and cumulative TBIs was also found (β = .580 [.283]; P = .04). Conclusions and Relevance: Suicide risk is higher among military personnel with more lifetime TBIs, even after controlling for clinical symptom severity. Results suggest that multiple TBIs, which are common among military personnel, may contribute to increased risk for suicide.
Keywords: Suicide Prevention, Traumatic Brain Injury (TBI)
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Bryan CJ, Clemans TA, Hernandez AM, Rudd MD. Loss of consciousness, depression, posttraumatic stress disorder, and suicide risk among deployed military personnel with mild traumatic brain injury. J Head Trauma Rehabil. 2013 Jan;28(1):13-20.
OBJECTIVE: To identify clinical variables associated with suicidality in military personnel with mild traumatic brain injury (mTBI) while deployed to Iraq. SETTING: Outpatient TBI clinic on a US military base in Iraq. PARTICIPANTS: Military personnel (N = 158) referred to an outpatient TBI clinic for a standardized intake evaluation, 135 (85.4%) who had a diagnosis of mTBI and 23 (14.6%) who did not meet criteria for TBI. MAIN MEASURES: Suicidal Behaviors Questionnaire-Revised, Depression subscale of the Behavioral Health Measure-20, Posttraumatic Stress Disorder Checklist-Military Version, Insomnia Severity Index, self-report questionnaire, and clinical interview addressing TBI-related symptoms. RESULTS: Among patients with mTBI, increased suicidality was significantly associated with depression and the interaction of depression with posttraumatic stress disorder symptoms. Longer duration of loss of consciousness was associated with decreased likelihood for any suicidality. CONCLUSION: Assessment after TBI in a combat zone may assist providers in identifying those at risk for suicidality and making treatment recommendations for service members with mTBI.
Keywords: OEF/OIF/OND, Suicide Prevention, Traumatic Brain Injury (TBI)
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Bryan CJ, Hernandez AM, Allison S, Clemans T. Combat exposure and suicide risk in two samples of military personnel. J Clin Psychol. 2013 Jan;69(1):64-77.
OBJECTIVE: In light of increased suicidal behaviors among military personnel and veterans since the initiation of combat operations in Afghanistan and Iraq, questions have been raised about the potential causal role of combat. The objective of the current study was to identify any direct or indirect effects of combat exposure on suicide risk through depression symptom severity, posttraumatic stress disorder (PTSD) symptom severity, thwarted belongingness, perceived burdensomeness, and fearlessness about death, consistent with the interpersonal-psychological theory of suicide (Joiner, 2005). METHOD: Structural equation modeling was utilized with two separate samples of deployed military personnel, 1 nonclinical (n = 348; 89.7% male, mean age = 24.50) and 1 clinical (n = 219; 91.8% male, mean age = 27.88), to test the effects of combat exposure on suicide risk. RESULTS: Greater combat exposure was directly associated with fearlessness about death and PTSD symptom severity in both samples, but failed to show either a direct or indirect effect on suicide risk. PTSD symptom severity was strongly associated with depression symptom severity, which in turn was related to suicide risk directly (in the nonclinical sample) or indirectly through low belongingness and perceived burdensomeness (in the clinical sample). CONCLUSIONS: In both samples of deployed active duty military personnel, combat exposure was either unrelated to suicide risk or was too distally related to have a measurable effect. Results do not support the interpersonal-psychological theory's hypothesis that combat exposure should be indirectly related to suicide risk through acquired fearlessness of death.
Keywords: OEF/OIF/OND, PTSD, Suicide Prevention
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Calkins ME, Ray A, Gur RC, Freedman R, Green MF, Greenwood TA, Light GA, Nuechterlein KH, Olincy A, Radant AD, Seidman LJ, Siever LJ, Silverman JM, Stone WS, Sugar C, Swerdlow NR, Tsuang DW, Tsuang MT, Turetsky BI, Braff DL, Lazzeroni LC, Gur RE. Sex differences in familiality effects on neurocognitive performance in schizophrenia. Biol Psychiatry. 2013 May 15;73(10):976-84.
BACKGROUND: Numerous studies have documented that patients with schizophrenia show neurocognitive impairments, which are also heritable in schizophrenia families. In view of these findings, the current investigation tested the hypothesis that neurocognitive performance of schizophrenia probands can predict the neurocognitive performance of their unaffected family members. METHODS: Participants (n=1967; schizophrenia=369; first-degree relatives=1072; community comparison subjects=526) in the Consortium on the Genetics of Schizophrenia were administered the Penn Computerized Neurocognitive Battery. RESULTS: Consistent with prior work, probands showed significant neurocognitive impairment, and neurocognitive ability was significantly heritable across domains. On average, unaffected relatives did not differ from community comparison subjects in their neurocognitive performance. However, in six of seven domains, proband scores predicted the performance of their unaffected siblings. Male, but not female, proband performance was predictive of their unaffected relatives' (siblings and mothers) performance, most consistently in face memory and spatial processing. CONCLUSIONS: Using a novel approach in which individual probands are paired with their respective unaffected relatives within each family, we found that male proband performance predicted both sister and brother performance, an effect that was most powerfully observed for face memory and spatial processing. Results suggest that the familial transmission of sexually dimorphic neurocognitive domains, in which a particular sex tends to show a performance advantage over the other, may not itself be sex specific in schizophrenia families. Copyright © 2013 Society of Biological Psychiatry. Published by Elsevier Inc. All rights reserved.
Keywords: Psychotic Disorders (schizophrenia, bipolar, SMI, etc), Brain (Neuroanatomy, Neurocognition, Neurotransmitters, etc)
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Chang M, Wortzel HS, Martinez R: Protecting the Rights of Defendants in Cases Where the Question of Competency Has Been Raised. Journal of the American Academy of Psychiatry and the Law 41(3): 463-465, 2013
Abstract not available
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Churchwell JC, Lopez-Larson M, Yurgelun-Todd DA. Orbitofrontal cortex and neuromaturation: a gateway to risk? Biol Psychiatry. 2012 Apr 15;71(8):664-5.
Abstract not available
Keywords: Substance Abuse
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Churchwell JC, Yurgelun-Todd DA. Age-related changes in insula cortical thickness and impulsivity: significance for emotional development and decision-making. Dev Cogn Neurosci. 2013 Oct;6:80-6.
Insula function has been associated with emotional regulation, adjusting to changing outcomes under risk, reward and loss anticipation, discounting of future rewards, and self-rated impulsivity. The role of the insula in these processes may be fundamentally related to prospective thinking, a trait that increases with age. There is evidence that insular cortical thickness shows age related decreases that parallel age related increases in future orientation and planning. We tested the hypothesis that nonplanning decreases with age and that insula thickness is related to both age and nonplanning impulsivity. Fifty-nine male and female participants, ranging in age from 10 to 22 years old, underwent structural magnetic resonance imaging (MRI) procedures and were assessed using the Barratt Impulsiveness Scale (BIS). We observed that anterior insula thickness and nonplanning impulsivity show an inverse relationship with age and that there is a significant positive linear relationship between anterior insula thickness and nonplanning.
Keywords: Brain (Neuroanatomy, Neurocognition, Neurotransmitters, etc)
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Davidson, C. L., Babson, K. A., Bonn-Miller, M. O., Souter, T. and Vannoy, S. (2013), The Impact of Exercise on Suicide Risk: Examining Pathways through Depression, PTSD, and Sleep in an Inpatient Sample of Veterans. Suicide and Life-Threat Behavi.
Suicide has a large public health impact. Although effective interventions exist, the many people at risk for suicide cannot access these interventions. Exercise interventions hold promise in terms of reducing suicide because of their ease of implementation. While exercise reduces depression, and reductions in depressive symptoms are linked to reduced suicidal ideation, no studies have directly linked exercise and suicide risk. The current study examined this association, including potential mediators (i.e., sleep disturbance, posttraumatic stress symptoms, and depression), in a sample of Veterans. SEM analyses revealed that exercise was directly and indirectly associated with suicide risk. Additionally, exercise was associated with fewer depressive symptoms and better sleep patterns, each of which was, in turn, related to lower suicide risk.
Keywords: Suicide Prevention
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Davidson, C. L., & Wingate, L. R. (2013). The glass half-full or a hopeful outlook: Which explains more variance in interpersonal suicide risk in a psychotherapy clinic sample? Journal of Positive Psychology, 8, 263-272.
Recent research has suggested that constructs in the field of positive psychology may be important for understanding suicide risk. Specifically, both hope theory and dispositional optimism have been linked to lower levels of suicidal ideation and interpersonal suicide risk. Despite these encouraging findings, no study has investigated the relationships between hope, optimism, and suicide risk in a clinical sample. The current study aimed to address this gap and to determine if hope or optimism was more important for understanding suicide risk as operationalized by the interpersonal-psychological theory and suicidal ideation. Results of hierarchical regression analyses revealed that both hope and optimism predicted lower levels of burdensomeness and thwarted belongingness, but were not significant predictors of suicidal ideation. Further, results revealed that when both hope and optimism were entered into a hierarchical regression in the final step, only optimism remained significant. Theoretical and clinical implications of these findings are discussed.
Keywords: Suicide Prevention
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Greenwood TA, Swerdlow NR, Gur RE, Cadenhead KS, Calkins ME, Dobie DJ, Freedman R, Green MF, Gur RC, Lazzeroni LC, Nuechterlein KH, Olincy A, Radant AD, Ray A, Schork NJ, Seidman LJ, Siever LJ, Silverman JM, Stone WS, Sugar CA, Tsuang DW, Tsuang MT, Turetsky BI, Light GA, Braff DL. Genome-wide linkage analyses of 12 endophenotypes for schizophrenia from the Consortium on the Genetics of Schizophrenia. Am J Psychiatry. 2013 May 1;170(5):521-32.
OBJECTIVE: The Consortium on the Genetics of Schizophrenia has undertaken a large multisite study to characterize 12 neurophysiological and neurocognitive endophenotypic measures as a step toward understanding the complex genetic basis of schizophrenia. The authors previously demonstrated the heritability of these endophenotypes; in the present study, genetic linkage was evaluated. METHOD: Each family consisted of a proband with schizophrenia, at least one unaffected sibling, and both parents. A total of 1,286 participants from 296 families were genotyped in two phases, and 1,004 individuals were also assessed for the endophenotypes. Linkage analyses of the 6,055 single-nucleotide polymorphisms that were successfully assayed, 5,760 of which were common to both phases, were conducted using both variance components and pedigree-wide regression methods. RESULTS: Linkage analyses of the 12 endophenotypes collectively identified one region meeting genome-wide significance criteria, with a LOD (log of odds) score of 4.0 on chromosome 3p14 for the antisaccade task, and another region on 1p36 nearly meeting genome-wide significance, with a LOD score of 3.5 for emotion recognition. Chromosomal regions meeting genome-wide suggestive criteria with LOD scores >2.2 were identified for spatial processing (2p25 and 16q23), sensorimotor dexterity (2q24 and 2q32), prepulse inhibition (5p15), the California Verbal Learning Test (8q24), the degraded-stimulus Continuous Performance Test (10q26), face memory (10q26 and 12p12), and the Letter-Number Span (14q23). CONCLUSIONS: Twelve regions meeting genome-wide significant and suggestive criteria for previously identified heritable, schizophrenia-related endophenotypes were observed, and several genes of potential neurobiological interest were identified. Replication and further genomic studies are needed to assess the biological significance of these results.
Keywords: Psychotic Disorders (schizophrenia, bipolar, SMI, etc), Genetics & Molecular Biology
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Gutierrez, P. M., Brenner, L. A., Rings, J. A., Devore, M. D., Kelly, P. J., Staves, P. J., Kelly, C. M., & Kaplan, M. S. (2013). A qualitative description of female veterans’ deployment-related experiences and potential suicide risk factors. Journal of Clinical Psychology, 69, 923-935.
OBJECTIVE: A qualitative study among female Veterans from recent conflicts was conducted to explore the women's experiences and potential suicide risk factors according to the Interpersonal Psychological Theory of Suicide, including burdensomeness, failed belongingness, and acquired ability. METHODS: The presented paper is an extension of published work by Brenner et al. (2008) regarding mostly male combat Veterans. The methodology employed was qualitative descriptive with hermeneutic hues (Sandelowski, 2000). Interviews were conducted with 19 women, aged 24-52 years, all of whom had been deployed to combat zones in Iraq and/or Afghanistan. RESULTS: Transcripts were reviewed and themes emerged regarding women being a minority within their environment and deployment-related stressors. These experiences seemed to influence participants' views of the world and ways of coping. CONCLUSIONS: Among the interviewed female Veterans, preliminary support was provided for Joiner's concepts. Therapeutic strategies for applying themes to clinical practice (e.g., peer support, family therapy, interventions aimed at increasing distress tolerance) are provided. © 2013 Wiley Periodicals, Inc.
Keywords: Gender Specific Care, Suicide Prevention
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Han DH, Kim SM, Choi JE, Min KJ, Renshaw PF. Adjunctive aripiprazole therapy with escitalopram in patients with co-morbid major depressive disorder and alcohol dependence: clinical and neuroimaging evidence. J Psychopharmacol. 2013 Mar;27(3):282-91.
The effective treatment of depression has been reported to reduce the severity of alcohol use, potentially reflecting improvements in common brain reward circuits. We hypothesized that augmentation therapy of escitalopram with aripiprazole would improve depressive symptoms as well as reduce craving for alcohol and cue-induced brain activity in patients with co-morbid alcohol dependence and major depressive disorder, compared with treatment with escitalopram alone. Thirty-five subjects with major depressive disorder and alcohol dependence were recruited and randomly assigned into 17 aripiprazole + escitalopram and 18 escitalopram only groups. At baseline and following six weeks of treatment, symptoms of depression, craving for alcohol and brain activity were evaluated. During the six week treatment period, Beck Depression Inventory and clinical global index-severity (CGI-S) scores decreased in both the aripiprazole + escitalopram and escitalopram only groups. In addition, following the treatment period, the Korean alcohol urge questionnaire scores in the aripiprazole + escitalopram group were reduced from 23.3±8.4 to 14.3±4.9, compared with those of the escitalopram group of from 21.6±8.4 to 19.3±7.1 (F=13.1, p<0.01). The activity within the anterior cingulate was increased in response to the presentation of alcohol drinking scenes following treatment in the aripiprazole + escitalopram group. The change of brain activity within the left anterior cingulate gyrus in all patients with co-morbid alcohol dependence and major depressive disorder was negatively correlated with the change in craving for alcohol. These findings suggest that the effects of aripiprazole on anterior cingulate cortex might mediate the successful treatment of alcohol dependence in patients with major depressive disorder.
Keywords: Depression
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Harper DG, Jensen JE, Ravichandran C, Sivrioglu Y, Silveri M, Iosifescu DV, Renshaw PF, Forester BP. Tissue-specific differences in brain phosphodiesters in late-life major depression. Am J Geriatr Psychiatry. 2014 May;22(5):499-509.
OBJECTIVE: Late-life depression has been hypothesized to have a neurodegenerative component that leads to impaired executive function and increases in subcortical white matter hyperintensities. Phosphorus magnetic resonance spectroscopy (MRS) can quantify several important phosphorus metabolites in the brain, particularly the anabolic precursors and catabolic metabolites of the constituents of cell membranes, which could be altered by neurodegenerative activity. METHODS: Ten patients with late-life major depression who were medication free at time of study and 11 aged normal comparison subjects were studied using (31)P MRS three-dimensional chemical shift imaging at 4 Tesla. Phosphatidylcholine and phosphatidylethanolamine comprise 90% of cell membranes in brain but cannot be quantified precisely with (31)P MRS. We measured phosphocholine and phosphoethanolamine, which are anabolic precursors, as well as glycerophosphocholine and glycerophosphoethanolamine, which are catabolic metabolites of phosphatidylcholine and phosphatidylethanolamine. RESULTS: In accordance with our hypotheses, glycerophosphoethanolamine was elevated in white matter of depressed subjects, suggesting enhanced breakdown of cell membranes in these subjects. Glycerophosphocholine did not show any significant difference between comparison and depressed subjects but both showed an enhancement in white matter compared with gray matter. Contrary to our hypotheses, neither phosphocholine nor phosphoethanolamine showed evidence for reduction in late-life depression. CONCLUSION: These findings support the hypothesis that neurodegenerative processes occur in white matter in patients with late-life depression more than in the normal elderly population. Copyright © 2014 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.
Keywords: Depression
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Harper DG, Plante DT, Jensen JE, Ravichandran C, Buxton OM, Benson KL, O'Connor SP, Renshaw PF, Winkelman JW. Energetic and cell membrane metabolic products in patients with primary insomnia: a 31-phosphorus magnetic resonance spectroscopy study at 4 tesla. Sleep. 2013 Apr 1;36(4):493-500.
STUDY OBJECTIVES: Primary insomnia (PI) is a sleep disorder characterized by difficulty with sleep initiation, maintenance, and/or the experience of nonrestorative sleep combined with a subsequent impairment of daytime functioning. The hyperarousal hypothesis has emerged as the leading candidate to explain insomnia symptoms in the absence of specific mental, physical, or substance-related causes. We hypothesized that the cellular energetic metabolites, including beta nucleoside triphosphate, which in magnetic resonance spectroscopy approximates adenosine triphosphate (ATP), and phosphocreatine (PCr), would show changes in PI reflecting increased energy demand. DESIGN AND SETTING: Matched-groups, cross-sectional study performed at two university-based hospitals. PATIENTS: Sixteen medication-free individuals (eight males, eight females; mean ± standard deviation (SD) age = 37.2 ± 8.4 y) with PI and 16 good sleepers (nine males, seven females; mean ± SD age = 37.6 ± 4.7 y). MEASUREMENTS: Diagnosis was established for all individuals by unstructured clinical interview, Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID), sleep diary, and actigraphy. Polysomnography was collected in individuals with PI. Phosphorous magnetic resonance spectroscopy (31P MRS) data were collected on all individuals at 4 Tesla. We assessed cell membrane (anabolic precursors and catabolic metabolites) and bioenergetic (ATP, phosphocreatine) metabolites in gray matter and white matter to determine their relationship to the presence and severity of PI. RESULTS: Individuals with PI showed lower phosphocreatine in gray matter and an unexpected decrease of phosphocholine, a precursor of the cell membrane compound phosphatidylcholine, in white matter. In addition, there was a trend toward a negative association between polysomnographically determined wake after sleep onset and gray matter beta-nucleoside triphosphate and white matter phosphocholine in the primary insomnia group. CONCLUSIONS: These results support the hyperarousal hypothesis in PI based on lower phosphocreatine in gray matter in the PI group.
Keywords: Sleep
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Hastings-Tolsma M, Matthews EE, Nelson JM, Schmiege S. Comparative effectiveness research: nursing science and health care delivery. West J Nurs Res. 2013 Jul;35(6):683-702.
Comparative effectiveness research (CER) is an important foundation in the development of scientific evidence that can assist patients, clinicians, and policy makers in making decisions that improve patient and system outcomes, including cost. CER is a part of what is now called dissemination and implementation science, which focuses on translating knowledge into practice by facilitating stakeholder access to more interpretable findings. CER has evolved from a rich history that aims to compare the effectiveness of select clinical treatments, approaches, or programs. This article describes the development of CER, approaches to designing and analyzing this research, and resources useful in generating such knowledge by nurse scientists.
Keywords: Translational (research)
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Henry ME, Bolo NR, Zuo CS, Villafuerte RA, Cayetano K, Glue P, Damle BD, Andrews E, Lauriat TL, Rana NS, Churchill JH, Renshaw PF. Quantification of brain voriconazole levels in healthy adults using fluorine magnetic resonance spectroscopy. Antimicrob Agents Chemother. 2013 Nov;57(11):5271-6.
Voriconazole is more effective for aspergillosis infections with central nervous system involvement than other antifungal agents. The clinical efficacy of voriconazole for central nervous system infections has been attributed to its ability to cross the blood-brain barrier. However, pharmacokinetic studies are limited to plasma and cerebrospinal fluid, so it remains unclear how much of the drug enters the brain. Fluorinated compounds such as voriconazole can be quantified in the brain using fluorine-19 magnetic resonance spectroscopy (MRS). Twelve healthy adult males participated in a pharmacokinetic analysis of voriconazole levels in the brain and plasma. Open-label voriconazole was dosed per clinical protocol with a loading dose of 400 mg every 12 h on day 1, followed by 200 mg every 12 h administered orally over a 3-day period. MRS was performed before and after dosing on the third day. Voriconazole levels in the brain exceeded the MIC for Aspergillus. The brain/plasma ratios were 3.0 at steady state on day 3 (predose) and 1.9 postdose. We found that voriconazole is able to penetrate the brain tissue, which can be quantified using a noninvasive MRS technique. (This study has been registered at ClinicalTrials.gov under registration no. NCT00300677.).
Keywords: Neuroimaging
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Henry ME, Lauriat TL, Lowen SB, Churchill JH, Hodgkinson CA, Goldman D, Renshaw PF. Effects of citalopram and escitalopram on fMRI response to affective stimuli in healthy volunteers selected by serotonin transporter genotype. Psychiatry Res. 2013 Sep 30;213(3):217-24.
This study was designed to assess whether functional magnetic resonance imaging (fMRI) following antidepressant administration (pharmaco-fMRI) is sufficiently sensitive to detect differences in patterns of activation between enantiomers of the same compound. Healthy adult males (n=11) participated in a randomized, double-blind, cross-over trial with three medication periods during which they received citalopram (racemic mixture), escitalopram (S-citalopram alone), or placebo for 2 weeks. All participants had high expression serotonin transporter genotypes. An fMRI scan that included passive viewing of overt and covert affective faces and affective words was performed after each medication period. Activation in response to overt faces was greater following escitalopram than following citalopram in the right insula, thalamus, and putamen when the faces were compared with a fixation stimulus. For the rapid covert presentation, a greater response was observed in the left middle temporal gyrus in the happy versus fearful contrast following escitalopram than following citalopram. Thus, the combination of genomics and fMRI was successful in discriminating between two very similar drugs. However, the pattern of activation observed suggests that further studies are indicated to understand how to optimally combine the two techniques. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.
Keywords: Neuroimaging
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Homaifar B, Matarazzo B, Wortzel HS. Therapeutic risk management of the suicidal patient: augmenting clinical suicide risk assessment with structured instruments. J Psychiatr Pract. 2013 Sep;19(5):406-9.
This column is the second in a series presenting a model for therapeutic risk management of the suicidal patient. As discussed in the first part of the series, the model involves several elements including augmenting clinical risk assessment with structured instruments, stratifying risk in terms of both severity and temporality, and developing and documenting a safety plan. This column explores in more detail how to augment clinical risk assessment with structured instruments. Unstructured clinical interviews have the potential to miss important aspects of suicide risk assessment. By augmenting the free-form clinical interview with structured instruments that demonstrate reliability and validity, a more nuanced and multifaceted approach to suicide risk assessment is achieved. Incorporating structured instruments into practice also serves a medicolegal function, since these instruments may become a living part of the medical record, establishing baseline levels of suicidal thoughts and behaviors and facilitating future clinical determinations regarding safety needs. We describe several instruments used in a multidisciplinary suicide consultation service, each of which has demonstrated relevance to suicide risk assessment and screening, ease of administration, and strong psychometric properties. In addition, we emphasize the importance of viewing suicide risk assessment as an ongoing process rather than as a singular event. Finally, we discuss special considerations in the evolving practice of risk assessment. (Journal of Psychiatric Practice 2013;19:406-409).
Keywords: Suicide Prevention
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Jeong HS, Lee S, Yoon S, Jung JJ, Cho HB, Kim BN, Ma J, Ko E, Im JJ, Ban S, Renshaw PF, Lyoo IK. Morphometric abnormalities of the lateral ventricles inmethamphetamine-dependent subjects. Drug Alcohol Depend. 2013 Aug 1;131(3):222-9.
BACKGROUND: The presence of morphometric abnormalities of the lateral ventricles, which can reflect focal or diffuse atrophic changes of nearby brain structures, is not well characterized in methamphetamine dependence. The current study was aimed to examine the size and shape alterations of the lateral ventricles in methamphetamine-dependent subjects. METHODS: High-resolution brain structural images were obtained from 37 methamphetamine-dependent subjects and 25 demographically matched healthy individuals. Using a combined volumetric and surface-based morphometric approach, the structural variability of the lateral ventricles, with respect to extent and location, was examined. RESULTS: Methamphetamine-dependent subjects had an enlarged right lateral ventricle compared with healthy individuals. Morphometric analysis revealed a region-specific pattern of lateral ventricular expansion associated with methamphetamine dependence, which was mainly distributed in the areas adjacent to the ventral striatum, medial prefrontal cortex, and thalamus. CONCLUSIONS: Patterns of shape decomposition in the lateral ventricles may have relevance to the structural vulnerability of the prefrontal-ventral striatal-thalamic circuit to methamphetamine-induced neurotoxicity. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.
Keywords: Substance Abuse, Neuroimaging
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Judah, M. R., Grant, D. M., Mills, A. C., Lechner, W. V., Slish, M. L., Davidson, C. L., & Wingate, L. R. (2013). The prospective role of depression, anxiety, and worry in stress generation. Journal of Social and Clinical Psychology, 32, 381-399.
Generalized Anxiety Disorder is characterized by worry and somatic anxiety symptoms which may generate dependent negative events and convey risk for depression. The current study prospectively examined the role of anxiety, worry, and depression in stress generation among an unselected undergraduate sample using a cross-lagged panel design with data collected at three time points. Results partially supported the role of depressive symptoms and anxiety symptoms as risk factors for dependent events. However, the role of worry in stress generation was not supported. The current study also suggested that anxiety symptoms serve as a risk factor for the development of depressive symptoms and that depressive symptoms mediate the association between anxiety symptoms and negative life events over time. These findings partially support the role of anxiety in the stress generation process and are consistent with a model of sequential comorbidity in which anxiety symptoms convey risk for depression. The importance of the current findings for the broad stress generation literature and the nature of comorbidity between GAD and MDD are discussed.
Keywords: Seriously Mentally Ill (SMI)
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Kaufman, M.J., Janes, A.C., Frederick, B.D., Brimson-Théberge, M., Tong, Y., McWilliams, S.B., Bear, A., Gillis, T.E., Schrode, K.M., Renshaw, P., & Stevens Negus, S. (2013). A method for conducting functional MRI studies in alert nonhuman primates: Initial results with opioid agonists in male cynomolgus monkeys. Experimental and Clinical Psychopharmacology, 21, 323-331.
Functional MRI (fMRI) has emerged as a powerful technique for assessing neural effects of psychoactive drugs and other stimuli. Several experimental approaches have been developed to use fMRI in anesthetized and awake animal subjects, each of which has its advantages and complexities. We sought to assess whether one particular method to scan alert postanesthetized animals can be used to assess fMRI effects of opioid agonists. To date, the use of fMRI as a method to compare pharmacological effects of opioid drugs has been limited. Such studies are important because mu and kappa opioid receptor agonists produce distinct profiles of behavioral effects related both to clinically desirable endpoints (e.g., analgesia) and to undesirable effects (e.g., abuse potential). This study sought to determine whether we could use our fMRI approach to compare acute effects of behaviorally equipotent (3.2 μg/kg) intravenous doses of fentanyl and U69,593 (doses that do not affect cardiorespiratory parameters). Scans were acquired in alert male cynomolgus macaques acclimated to undergo fMRI scans under restraint, absent excessive stress hormone increases. These opioid agonists activated bilateral striatal and nucleus accumbens regions of interest. At the dose tested, U69,593 induced greater left nucleus accumbens BOLD activation than fentanyl, while fentanyl activated left dorsal caudate nucleus more than U69,593. Our results suggest that our fMRI approach could be informative for comparing effects of opioid agonists.
Keywords: Neuroimaging
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Kim D, Cho HB, Dager SR, Yurgelun-Todd DA, Yoon S, Lee JH, Lee SH, Lee S, Renshaw PF, Lyoo IK. Posterior cerebellar vermal deficits in bipolar disorder. J Affect Disord. 2013 Sep 5;150(2):499-506.
BACKGROUND: Based on growing evidence of the crucial role of the cerebellum in emotional regulation, we sought to identify cerebellar structural deficits in a large sample of patients with bipolar disorder (BD). METHODS: Cerebellar gray matter density was examined in 49 BD patients (24 medication-naive and 25 medication-treated) and 50 carefully matched healthy individuals, using voxel-based morphometry with a high-resolution spatially unbiased atlas template of the human cerebellum. This recently developed methodology is specifically optimized for the assessment of cerebellar structures. We further explored whether antimanic treatment could attenuate cerebellar structural deficits. RESULTS: BD patients showed a greater reduction in gray matter density of the posterior cerebellar regions, including the bilateral vermi and the right crus relative to healthy individuals (corrected p<.05). A stepwise linear reduction in gray matter density was observed in bilateral vermal regions between healthy individuals, medication-treated, and medication-naive BD patients. Furthermore, positive correlations of longer duration of illness with bilateral vermal gray matter deficits were observed only in medication-naive BD patients, but not in patients with medication history. LIMITATIONS: This study adopted a cross-sectional design. The automatic intensity-normalization method for the measurement of cerebellar gray matter density may have a limitation in providing detailed anatomical information at a cerebellar folia level. CONCLUSIONS: The current findings suggest that BD-related deficits in the posterior cerebellar regions, which appear to progress over the course of illness, could potentially be ameliorated by proper treatment with mood stabilizers. Copyright © 2013 Elsevier B.V. All rights reserved.
Keywords: Neuroimaging, Mood Disorder
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Konopaske GT, Bolo NR, Basu AC, Renshaw PF, Coyle JT. Time-dependent effects of haloperidol on glutamine and GABA homeostasis and astrocyte activity in the rat brain. Psychopharmacology (Berl). 2013 Nov;230(1):57-67.
RATIONALE: Schizophrenia is a severe, persistent, and fairly common mental illness. Haloperidol is widely used and is effective against the symptoms of psychosis seen in schizophrenia. Chronic oral haloperidol administration decreased the number of astrocytes in the parietal cortex of macaque monkeys (Konopaske et al., Biol Psych 63:759-765, 2008). Since astrocytes play a key role in glutamate metabolism, chronic haloperidol administration was hypothesized to modulate astrocyte metabolic function and glutamate homeostasis. OBJECTIVES: This study investigated the effects of chronic haloperidol administration on astrocyte metabolic activity and glutamate, glutamine, and GABA homeostasis. METHODS: We used ex vivo ¹³C magnetic resonance spectroscopy along with high-performance liquid chromatography after [1-¹³C]glucose and [1,2-¹³C]acetate administration to analyze forebrain tissue from rats administered oral haloperidol for 1 or 6 months. RESULTS: Administration of haloperidol for 1 month produced no changes in ¹³C labeling of glutamate, glutamine, or GABA, or in their total levels. However, a 6-month haloperidol administration increased ¹³C labeling of glutamine by [1,2-¹³C]acetate. Moreover, total GABA levels were also increased. Haloperidol administration also increased the acetate/glucose utilization ratio for glutamine in the 6-month cohort. CONCLUSIONS: Chronic haloperidol administration in rats appears to increase forebrain GABA production along with astrocyte metabolic activity. Studies exploring these processes in subjects with schizophrenia should take into account the potential confounding effects of antipsychotic medication treatment.
Keywords: Brain (Neuroanatomy, Neurocognition, Neurotransmitters, etc)
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Lee JH, Yoon S, Renshaw PF, Kim TS, Jung JJ, Choi Y, Kim BN, Jacobson AM, Lyoo IK. Morphometric changes in lateral ventricles of patients with recent-onset type 2 diabetes mellitus. PLoS One. 2013 Apr 4;8(4):e60515.
It is becoming increasingly evident that type 2 diabetes mellitus can have effects on global and regional brain morphology. Ventricular enlargement reflecting cerebral atrophy has been reported particularly in elderly type 2 diabetes patients. However, little is known about its timing through the disease course and morphological variability. Using the combined volumetric and advanced three-dimensional morphological approach, we identified differences in size and shape of the lateral ventricles between recent-onset type 2 diabetes patients and healthy individuals. High-resolution T1-weighted images were obtained from 23 type 2 diabetes patients whose illness duration was less than 1 year and 23 carefully matched healthy individuals. By volume measurement, we found enlarged lateral and third ventricles in type 2 diabetes patients, relative to healthy individuals (F(1,41 )= 7.96, P = 0.007; F(1,41) = 11.16, P = 0.002, respectively). Morphological analysis revealed that the expansion of lateral ventricles in the diabetic brain was prominent in the bilateral frontal horns. The current findings suggest that atrophic changes particularly of the anterior frontal lobe can occur as early as the first year after the clinical diagnosis of type 2 diabetes mellitus.
Keywords: Brain (Neuroanatomy, Neurocognition, Neurotransmitters, etc), Physical Disorders (comorbid medical: e.g. Diabetes, Hep C, etc)
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Lee YS, Han DH, Kim SM, Renshaw PF. Substance abuse precedes Internet addiction. Addict Behav. 2013 Apr;38(4):2022-5.
The purpose of the current study was to evaluate possible overlapping substance abuse and internet addiction in a large, uniformly sampled population, ranging in age from 13 to 18 years. Participants (N=73,238) in the current study were drawn from the 6th Korea Youth Risk Behavior Web-based Survey (KYRBWS-V) for students from 400 middle schools and 400 high schools in 16 cities within South Korea. Of adolescent internet users, 85.2% were general users (GU), 11.9% were users with potential risk for internet addiction (PR), and 3.0% were users with high risk for internet addiction (HR). There was a difference in the number of students with alcohol drinking among the GU, PR, and HR groups (20.8% vs 23.1% vs 27.4%). There was a difference in the number of students who smoked among the GS, PR, and HR groups (11.7% vs 13.5% vs 20.4%). There was a difference in the number of students with drug use among the GU, PR, and HR groups (1.7% vs 2.0% vs 6.5%). After adjusting for sex, age, stress, depressed mood, and suicidal ideation, smoking may predict a high risk for internet addiction (OR=1.203, p=0.004). In addition, drug use may predict a high risk for internet addiction (OR=2.591, p<0.001). Because students with a high risk for internet addiction have vulnerability for addictive behaviors, co-morbid substance abuse should be evaluated and, if found, treated in adolescents with internet addiction.
Keywords: Substance Abuse
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Lopez-Larson M, King JB, McGlade E, Bueler E, Stoeckel A, Epstein DJ, Yurgelun-Todd D. Enlarged thalamic volumes and increased fractional anisotropy in the thalamic radiations in veterans with suicide behaviors. Front Psychiatry. 2013 Aug 12;4:83.
Post-mortem studies have suggested a link between the thalamus, psychiatric disorders, and suicide. We evaluated the thalamus and anterior thalamic radiations (ATR) in a group of Veterans with and without a history of suicidal behavior (SB) to determine if thalamic abnormalities were associated with an increased risk of SB. Forty Veterans with mild traumatic brain injury (TBI) and no SB (TBI-SB), 19 Veterans with mild TBI and a history of SB (TBI + SB), and 15 healthy controls (HC) underwent magnetic resonance imaging scanning including a structural and diffusion tensor imaging scan. SBs were evaluated utilizing the Columbia Suicide Rating Scale and impulsivity was measured using the Barratt Impulsiveness Scale (BIS). Differences in thalamic volumes and ATR fractional anisotropy (FA) were examined between (1) TBI + SB versus HC and (2) TBI + SB versus combined HC and TBI-SB and (3) between TBI + SB and TBI-SB. Left and right thalamic volumes were significantly increased in those with TBI + SB compared to the HC, TBI-SB, and the combined group. Veterans with TBI + SB had increased FA bilaterally compared to the HC, HC and TBI-SB group, and the TBI-SB only group. Significant positive associations were found for bilateral ATR and BIS in the TBI + SB group. Our findings of thalamic enlargement and increased FA in individuals with TBI + SB suggest that this region may be a biomarker for suicide risk. Our findings are consistent with previous evidence indicating that suicide may be associated with behavioral disinhibition and frontal-thalamic-limbic dysfunction and suggest a neurobiologic mechanism that may increase vulnerability to suicide.
Keywords: Neuroimaging
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Lugo-Sanchez W, Wortzel HS, Martinez R: Appropriate Use of Extreme Emotional Distress Defense. Journal of the American Academy of Psychiatry and the Law 41(3):461-463, 2013
Abstract not available
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Lyoo IK, Yoon S, Renshaw PF, Hwang J, Bae S, Musen G, Kim JE, Bolo N, Jeong HS, Simonson DC, Lee SH, Weinger K, Jung JJ, Ryan CM, Choi Y, Jacobson AM. Network-level structural abnormalities of cerebral cortex in type 1 diabetes mellitus. PLoS One. 2013 Aug 23;8(8):e71304.
Type 1 diabetes mellitus (T1DM) usually begins in childhood and adolescence and causes lifelong damage to several major organs including the brain. Despite increasing evidence of T1DM-induced structural deficits in cortical regions implicated in higher cognitive and emotional functions, little is known whether and how the structural connectivity between these regions is altered in the T1DM brain. Using inter-regional covariance of cortical thickness measurements from high-resolution T1-weighted magnetic resonance data, we examined the topological organizations of cortical structural networks in 81 T1DM patients and 38 healthy subjects. We found a relative absence of hierarchically high-level hubs in the prefrontal lobe of T1DM patients, which suggests ineffective top-down control of the prefrontal cortex in T1DM. Furthermore, inter-network connections between the strategic/executive control system and systems subserving other cortical functions including language and mnemonic/emotional processing were also less integrated in T1DM patients than in healthy individuals. The current results provide structural evidence for T1DM-related dysfunctional cortical organization, which specifically underlie the top-down cognitive control of language, memory, and emotion.
Keyword: Brain (Neuroanatomy, Neurocognition, Neurotransmitters, etc)
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Matarazzo, B. B., Clemans, T. A., Silverman, M. M., & Brenner, L. A. (2013). The Self-Directed Violence Classification System and the Columbia Classification Algorithm for Suicide Assessment: A crosswalk. Suicide and Life-Threatening Behavior, 43, 235-249.
The lack of a standardized nomenclature for suicide-related thoughts and behaviors prompted the Centers for Disease Control and Prevention, with the Veterans Integrated Service Network 19 Mental Illness Research Education and Clinical Center, to create the Self-Directed Violence Classification System (SDVCS). SDVCS has been adopted by the Department of Veterans Affairs and the Department of Defense. Another classification system, the Columbia Classification Algorithm for Suicide Assessment, has been recommended by the Food and Drug Administration. To facilitate the use of both systems, this article provides a "crosswalk" between the two classification systems.
Keywords: Suicide Prevention
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Matarazzo, B. E., Wortzel, H., Dorsey Holliman, B., & Brenner, L. (2013). Evidence-based intervention strategies for veterans and military personnel with traumatic brain injury and co-morbid mental health conditions: a systematic review. Brain Impairment.
No abstract
Keywords: Traumatic Brain Injury
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Matthews EE
, Arnedt JT, McCarthy MS, Cuddihy LJ, Aloia MS. Adherence to cognitive behavioral therapy for insomnia: a systematic review. Sleep Med Rev. 2013 Dec;17(6):453-64.
Chronic insomnia is a significant public health problem worldwide, and insomnia has considerable personal and social costs associated with serious health conditions, greater healthcare utilization, work absenteeism, and motor-vehicle accidents. Cognitive behavioral therapy for insomnia (CBTI) is an efficacious treatment, yet attrition and suboptimal adherence may diminish its impact. Despite the increasing use of CBTI, surprisingly little attention has been devoted to understanding the role of adherence. This review describes a comprehensive literature search of adherence to CBTI. The search revealed 15 studies that evaluated adherence to CBTI in adults using valid and reliable measures of sleep, and measure of adherence other than study withdrawals. The primary purposes of this review were to 1) synthesize current study characteristics, methodology, adherence rates, contributing factors, and impact on outcomes, 2) discuss measurement issues, and 3) identify future practice and research directions that may lead to improved outcomes. Strong patterns and inconsistencies were identified among the studies, which complicate an evaluation of the role of adherence as a factor and outcome of CBTI success. The importance of standardized adherence and outcome measures is discussed. In light of the importance of adherence to behavior change, this systematic review may better inform future intervention efforts.
Keywords: Sleep
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Monteith LL, Menefee DS, Pettit JW, Leopoulos WL, Vincent JP. Examining the Interpersonal-Psychological Theory of Suicide in an Inpatient Veteran Sample. Suicide Life Threat Behav. 2013 Apr 5. doi: 10.1111/sltb.12027. [Epub ahead of print]
Suicide among veterans is a pressing public health concern. The interpersonal-psychological theory of suicide proposes that perceived burdensomeness and thwarted belongingness lead to suicidal desire, whereas the acquired capability for suicide leads to suicide attempt in the presence of suicidal desire (Joiner, 2005). Two hypotheses derived from the interpersonal-psychological theory of suicide were tested in 185 veterans (96 women) entering inpatient psychiatric treatment. Burdensomeness and its interaction with belongingness significantly predicted current suicidal ideation. The three-way interaction between burdensomeness, belongingness, and acquired capability did not significantly predict number of past suicide attempts. Clinical implications and directions for future research are discussed.
Keywords: Suicide Prevention 
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Nodine PM, Matthews EE. Common sleep disorders: management strategies and pregnancy outcomes. J Midwifery Womens Health. 2013 Jul-Aug;58(4):368-77.
Sleep disorders, prevalent in industrialized countries, are associated with adverse health outcomes such as hypertension, diabetes, and obesity. Disturbed sleep during pregnancy is frequently overlooked by health care providers, yet recent studies suggest there is an association between sleep disorders and adverse pregnancy outcomes, including preeclampsia, elevated serum glucose, depression, prolonged labor, and cesarean birth. Growing evidence indicates that the recognition and management of prenatal sleep disorders may minimize adverse pregnancy outcomes and improve maternal and fetal well-being. This focused review of prenatal sleep disturbance literature suggests there are 3 main sleep disorders of interest: breathing-related sleep disorders (ie, habitual snoring and obstructive sleep apnea), restless legs syndrome, and insomnia. These sleep disorders are common in pregnancy and have maternal and fetal consequences if left untreated. This article describes sleep disorders of pregnancy, elucidates their relationship with maternal and neonatal outcomes, and presents current evidence regarding diagnostic and management strategies. © 2013 by the American College of Nurse-Midwives.
Keywords: Sleep
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Olson-Madden JH, Brenner LA, Matarazzo BB, Signoracci GM; Expert Consensus Collaborators. Identification and Treatment of TBI and Co-occurring Psychiatric Symptoms Among OEF/OIF/OND Veterans Seeking Mental Health Services Within the State of Colorado: Establishing Consensus for Best Practices. Community Ment Health J. 2013 Jan 17. [Epub ahead of print]
This paper highlights the results of a consensus meeting regarding best practices for the assessment and treatment of co-occurring traumatic brain injury (TBI) and mental health (MH) problems among Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn Veterans seeking care in non-Veterans Affairs Colorado community MH settings. Twenty individuals with expertise in TBI screening, assessment, and intervention, as well as the state MH system, convened to establish and review questions and assumptions regarding care for this Veteran population. Unanimous consensus regarding best practices was achieved. Recommendations for improving care for Veterans seeking care in community MH settings are provided.
Keywords: Assessment,OEF/OIF/OND, Traumatic Brain Injury (TBI)
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Patros, C., Hudec, K. L., Kasper, L. J., Alderson, R. M., Davidson, C. L., & Wingate, L. R. (2013). Symptoms of Attention Deficit/Hyperactivity Disorder (ADHD) moderate suicidal behaviors in college students with depressed mood. Journal of Clinical Psychology, 69, 980-993.
Objective: College students with attention-deficit/hyperactivity disorder-related hyperactive/impulsive (HI) and/or inattentive (IA) symptoms may be at greater risk for suicidal behavior due to core and secondary symptoms that increase their potential to engage in behaviors that put them at risk for suicidal behavior. Consequently, the current study examined the moderating effect of combined HI/IA symptoms, in addition to independent HI and IA symptoms on the relationship between depressed mood and suicidal thoughts and behavior. Method: A sample of 1,056 undergraduate students (61.5% female, 96.4% aged 18–24 years) provided self-report ratings of mood, suicidal behavior (thoughts, self-harm, attempts, and need for medical attention), and current HI/IA symptoms. Results: Significant moderation effects were detected, such that greater HI/IA symptoms were associated with a stronger relationship between depressed mood and suicidal ideation and attempts, but not self-harm. Current HI and IA symptoms significantly moderated the relationship between depressed mood and suicidal thoughts and suicide attempts, but did not moderate the relationship between depressed mood and self-harm and need for medical attention. Conclusions: The current findings suggest that the presence of combined HI/IA symptoms conveys increased suicide risk for depressed college students. Additionally, results suggest a complex relationship between independent HI and IA symptoms and severe suicidal outcomes. © 2013 Wiley Periodicals, Inc. J. Clin. Psychol. 69:980–993, 2013.
Keywords: Suicide Prevention
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Prescot AP, Renshaw PF. Two-dimensional J-resolved proton MR spectroscopy and prior knowledge fitting (ProFit) in the frontal and parietal lobes of healthy volunteers: assessment of metabolite discrimination and general reproducibility. J Magn Reson Imaging. 2013 Mar;37(3):642-51.
PURPOSE: To investigate human brain metabolite discriminability and general measurement reproducibility of two-dimensional (2D) J-resolved (1)H MRS and Prior Knowledge Fitting (ProFit). MATERIALS AND METHODS: 2D J-resolved (1)H MRS spectra were acquired from the anterior cingulate cortex (ACC) and the parietal-occipital cortex (POC) of 10 healthy subjects at a magnetic field strength of 2.9 Tesla. Amplitude correlation matrices were constructed for each subject and brain region to assess metabolite discriminability. ProFit-estimated metabolite peak areas were normalized to a water reference signal, and intra- and inter-subject reproducibility was evaluated. RESULTS: Favorable between-metabolite correlation coefficients (<20%) were observed for a range of metabolites. Lower correlation coefficients between a given pair of metabolite estimates were consistently observed for POC metabolites. The group mean correlation coefficient existing between glutamate and glutamine was calculated as -18% and -13% for ACC and POC, respectively. Most ACC and POC metabolites showed intra- and inter-subject CV values of <15% and <20%, respectively. CONCLUSION: The observed Glu and Gln signal discrimination makes these techniques suitable for investigating a variety of psychiatric disorders. Intra- and inter-subject metabolite level reproducibility was comparable to the existing literature findings. These data serve as a valuable benchmark for assessing future modifications to 2D (1)H MRS data acquisition and ProFit analysis. Copyright © 2012 Wiley Periodicals, Inc.
Keywords: Brain (Neuroanatomy, Neurocognition, Neurotransmitters, etc)
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Prescot AP, Renshaw PF, Yurgelun-Todd DA. γ-Amino butyric acid and glutamate abnormalities in adolescent chronic marijuana smokers. Drug Alcohol Depend. 2013 May 1;129(3):232-9.
BACKGROUND: An increasing body of evidence from neuropsychological and neuroimaging studies suggests that exposure to marijuana throughout adolescence disrupts key cortical maturation processes occurring during this developmental phase. GABA-modulating pharmacologic treatments that elevate brain GABA concentration recently have been shown to decrease withdrawal symptoms and improve executive functioning in marijuana-dependent adult subjects. The goal of this study was to investigate whether the lower ACC glutamate previously reported in adolescent chronic marijuana smokers is associated with lower ACC GABA levels. METHODS: Standard and metabolite-edited proton MRS data were acquired from adolescent marijuana users (N=13) and similarly aged non-using controls (N=16) using a clinical 3T MRI system. RESULTS: The adolescent marijuana-using cohort showed significantly lower ACC GABA levels (-22%, p=0.03), which paralleled significantly lower ACC glutamate levels (-14%, p=0.01). Importantly, the lower ACC GABA and glutamate levels detected in the adolescent cohort remained significant after controlling for age and sex. CONCLUSIONS: The present spectroscopic findings support functional neuroimaging data documenting cingulate dysfunction in marijuana-dependent adolescents. Glutamatergic and GABAergic abnormalities potentially underlie cingulate dysfunction in adolescent chronic marijuana users, and the opportunity for testing suitable pharmacologic treatments with a non-invasive pharmacodynamic evaluation exists. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.
Keywords: Substance Abuse
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Russell LM, Devore MD, Barnes SM, Forster JE, Hostetter TA, Montgomery AE, Casey R, Kane V, Brenner LA. Challenges associated with screening for traumatic brain injury among US veterans seeking homeless services. Am J Public Health. 2013 Dec;103 Suppl 2:S211-2. doi: 10.2105/AJPH.2013.301485. Epub 2013 Oct 22.
We identified the prevalence of traumatic brain injury (TBI) among homeless veterans and assessed the TBI-4, a screening tool created to identify TBI history. Between May 2010 and October 2011, 800 US veterans from two hospitals, one eastern (n = 122) and one western (n = 678) completed some or all measures. Findings suggested that 47% of veterans seeking homeless services had a probable history of TBI (data for prevalence obtained only at the western hospital). However, psychometric results from the screening measure suggested that this may be an underestimate and supported comprehensive assessment of TBI in this population.
Keywords: Traumatic Brain Injury (TBI)
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Sikoglu, E.M., Jensen, J.E., Vitaliano, G., Liso Navarro, A.A., Renshaw, P., Frazier, J.A., & Moore, S. (2013). Bioenergetic measurements in children with bipolar disorder: a pilot 31P magnetic resonance spectroscopy study. PLoS One, 8.
Abstract not available
Keywords: Psychotic Disorders (schizophrenia, bipolar, SMI, etc)
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Smith KM, Renshaw PF, Bilello J. The diagnosis of depression: current and emerging methods. Compr Psychiatry. 2013 Jan;54(1):1-6.
Depression is one of the leading causes of disability in adolescents and adults, particularly starting from age 15 years and older. Diagnosis of depression has traditionally been made based on clinical criteria, including patient current symptoms and history. This process is widely used but relies on subjective interpretation. To standardize both the data obtained and data interpretation, various interview-based instruments and noninterview methods exist for screening and testing for depression in various clinical settings. This article evaluates the technical basis for and clinical performance of these various instruments and methods to diagnosis depression in clinical settings. Traditional tools include physician-administered or patient self-administered interview tools that have reasonable clinical accuracy depending on the threshold score and may lead to a full diagnostic evaluation for high-risk patients. In addition, older laboratory methods such as the dexamethasone test have contributed to the diagnosis of depression over a long period. Newer diagnostic methods such as genomics, proteomics, and metabolomics are technically sophisticated and objective and are beginning to emerge in psychiatry. Although promising, further evaluation of these methods is needed to fully demonstrate their clinical value and accuracy. Copyright © 2013 Elsevier Inc. All rights reserved.
Keywords: Depression
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Sneider JT, Gruber SA, Rogowska J, Silveri MM, Yurgelun-Todd DA. A preliminary study of functional brain activation among marijuana users during performance of a virtual water maze task. J Addict. 2013;2013:461029.
Numerous studies have reported neurocognitive impairments associated with chronic marijuana use. Given that the hippocampus contains a high density of cannabinoid receptors, hippocampal-mediated cognitive functions, including visuospatial memory, may have increased vulnerability to chronic marijuana use. Thus, the current study examined brain activation during the performance of a virtual analogue of the classic Morris water maze task in 10 chronic marijuana (MJ) users compared to 18 non-using (NU) comparison subjects. Imaging data were acquired using blood oxygen-level dependent (BOLD) functional MRI at 3.0 Tesla during retrieval (hidden platform) and motor control (visible platform) conditions. While task performance on learning trials was similar between groups, MJ users demonstrated a deficit in memory retrieval. For BOLD fMRI data, NU subjects exhibited greater activation in the right parahippocampal gyrus and cingulate gyrus compared to the MJ group for the Retrieval - Motor control contrast (NU > MJ). These findings suggest that hypoactivation in MJ users may be due to differences in the efficient utilization of neuronal resources during the retrieval of memory. Given the paucity of data on visuospatial memory function in MJ users, these findings may help elucidate the neurobiological effects of marijuana on brain activation during memory retrieval.
Keywords: Substance Abuse
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Sung YH, Carey PD, Stein DJ, Ferrett HL, Spottiswoode BS, Renshaw PF, Yurgelun-Todd DA. Decreased frontal N-acetylaspartate levels in adolescents concurrently using both methamphetamine and marijuana. Behav Brain Res. 2013 Jun 1;246:154-61.
INTRODUCTION: The potential neurochemical toxicity associated with methamphetamine (MA) or marijuana (MJ) use on the developing adolescent brain is unclear, particularly with regard to individuals with concomitant use of MA and MJ (MA+MJ). In this study, proton magnetic resonance spectroscopy (MRS) was utilized to measure in vivo brain N-acetylaspartate plus N-acetylaspartyl glutamate (tNAA, an indicator of intact neuronal integrity) levels. METHODS: Three adolescent groups from Cape Town, South Africa completed MRS scans as well as clinical measures including a drug use history. Subjects included (1) nine MA (age=15.7±1.37), (2) eight MA+MJ (age=16.2±1.16) using adolescents and (3) ten healthy controls (age=16.8±0.62). Single voxel spectra were acquired from midfrontal gray matter using a point-resolved spectroscopy sequence (PRESS). The MRS data were post-processed in the fully automated approach for quantitation of metabolite ratios to phosphocreatine plus creatine (PCr+Cr). RESULTS: A significant reduction in frontal tNAA/PCr+Cr ratios was seen in the MA+MJ group compared to the healthy controls (p=0.01, by 7.2%) and to the MA group (p=0.04, by 6.9%). Significant relationships were also observed between decreased tNAA/PCr+Cr ratios and drug use history of MA or MJ (total cumulative lifetime dose, age of onset, and duration of MA and MJ exposure) only in the MA+MJ group (all p<0.05). CONCLUSIONS: These findings suggest that in adolescents, concomitant heavy MA+MJ use may contribute to altered brain metabolites in frontal gray matter. The significant associations between the abnormal tNAA/PCr+Cr ratios and the drug use history suggest that MA+MJ abuse may induce neurotoxicity in a dose-responsive manner in adolescent brain. Copyright © 2013 Elsevier B.V. All rights reserved.
Keywords: Substance Abuse
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Sung YH, Yurgelun-Todd DA, Shi XF, Kondo DG, Lundberg KJ, McGlade EC, Hellem TL, Huber RS, Fiedler KK, Harrell RE, Nickerson BR, Kim SE, Jeong EK, Renshaw PF. Decreased frontal lobe phosphocreatine levels in methamphetamine users. Drug Alcohol Depend. 2013 Apr 1;129(1-2):102-9.
BACKGROUND: Mitochondria-related mechanisms have been suggested to mediate methamphetamine (METH) toxicity. However, changes in brain energetics associated with high-energy phosphate metabolism have not been investigated in METH users. Phosphorus-31 ((31)P) magnetic resonance spectroscopy (MRS) was used to evaluate changes in mitochondrial high energy phosphates, including phosphocreatine (PCr) and β-nucleoside triphosphate (β-NTP, primarily ATP in brain) levels. We hypothesized that METH users would have decreased high-energy PCr levels in the frontal gray matter. METHODS: Study participants consisted of 51 METH (age=32.8±6.7) and 23 healthy comparison (age=31.1±7.5) subjects. High-energy phosphate metabolite levels were compared between the groups and potential gender differences were explored. RESULTS: METH users had lower ratios of PCr to total pool of exchangeable phosphate (PCr/TPP) in the frontal lobe as compared to the healthy subjects (p=.001). The lower PCr levels in METH subjects were significantly associated with lifetime amount of METH use (p=.003). A sub-analysis for gender differences revealed that female METH users, who had lower daily amounts (1.1±1.0g) of METH use than males (1.4±1.7g), had significantly lower PCr/TPP ratios than male METH users, controlling for the amount of METH use (p=.02). CONCLUSIONS: The present findings suggest that METH compromises frontal lobe high-energy phosphate metabolism in a dose-responsive manner. Our findings also suggest that the abnormality in frontal lobe high-energy phosphate metabolism might be more prominent in female than in male METH users. This is significant as decreased PCr levels have been associated with depressive symptoms, and poor responses to antidepressant treatment have been reported in those with decreased PCr levels. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.
Keywords: Brain (Neuroanatomy, Neurocognition, Neurotransmitters, etc)
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Topolovec-Vranic J, Ennis N, Ouchterlony D, Cusimano MD, Colantonio A, Hwang SW, Kontos P, Stergiopoulos V, Brenner L. Clarifying the link between traumatic brain injury and homelessness: workshop proceedings. Brain Inj. 2013;27(13-14):1600-5.
PURPOSE: To disseminate the proceedings of a 1-day multidisciplinary stakeholder workshop aimed at examining the inter-relationship between traumatic brain injury (TBI) and homelessness. METHODS: Thirty-seven stakeholders participated in the workshop, including frontline workers with individuals who are homeless, physicians, nurses and other healthcare workers, researchers, policy-makers, students and individuals with lived experience of homelessness. Didactic presentations, large group discussions and break-out sessions were used to disseminate knowledge, identify service and research gaps, develop a research agenda and facilitate networking. RESULTS: The participants identified barriers to service provision for individuals who are homeless and have sustained TBI with a focus on age- and gender-related issues, co-morbid TBI and mental illness and jurisdictional differences. Challenges and strategies related to engaging stakeholders in research with this population, as well as disseminating knowledge were discussed and research questions were identified. CONCLUSION: There is very little empirical literature on the topic of TBI and homelessness. The workshop identified key issues for consideration, including gaps in knowledge related to this topic.
Keywords: TBI, Homelessness
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Tucker RP, Wingate LR, O'Keefe VM, Mills AC, Rasmussen K, Davidson CL, Grant DM. Rumination and suicidal ideation: The moderating roles of hope and optimism. Personality and Individual Differences (2013)
The current study aimed to investigate whether the correlation between rumination and suicidal ideation is moderated by the presence of hope and optimism. It was hypothesized that both hope and optimism would moderate (weaken) the relationship between rumination and suicidal ideation. Two hundred and ninety-eight participants completed self-report measures of hope, optimism, rumination (brooding and reflection), and depression. Results demonstrated that both hope and optimism weakened the relationship between rumination and suicidal ideation, as well as the relationships between both subscales of rumination and suicidal thinking. These results were found when controlling for symptoms of depression. Results suggest that a ruminative thinking style may be most harmful when an absence of hope or optimism is also present.
Keywords: Suicide Prevention
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Winkelman JW, Plante DT, Schoerning L, Benson K, Buxton OM, O'Connor SP, Jensen JE, Renshaw PF, Gonenc A. Increased Rostral Anterior Cingulate Cortex Volume in Chronic Primary Insomnia. Sleep. 2013 Jul 1;36(7):991-998.
BACKGROUND: Recent studies document alterations in cortical and subcortical volumes in patients with chronic primary insomnia (PI) in comparison with normal sleepers. We sought to confirm this observation in two previously studied PI cohorts. METHODS: Two separate and independent groups of unmedicated patients who met Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV) criteria for PI were compared with two separate, healthy control groups (Study 1: PI = 20, controls = 15; Study 2: PI = 21, controls = 20). Both studies included 2 weeks of sleep diaries supplemented by wrist actigraphy. The 3.0 T MRI-derived rostral anterior cingulate cortex (rACC) volumes were measured with FreeSurfer image analysis suite (version 5.0) and results normalized to total intracranial volume (ICV). Unpaired t-tests (two-tailed) were used to compare rACC volumes between groups. Post hoc correlations of rACC volumes to insomnia severity measures were performed (uncorrected for multiplicity). RESULTS: Both studies demonstrated increases in normalized rACC volume in PI compared with control patients (Study 1: right side P = 0.05, left side P = 0.03; Study 2: right side P = 0.03, left side P = 0.02). In PI patients from Study 1, right rACC volume was correlated with sleep onset latency (SOL) by both diary (r = 0.51, P = 0.02) and actigraphy (r = 0.50, P = 0.03), and with sleep efficiency by actigraphy (r = -0.57, P = 0.01); left rACC volume was correlated with SOL by diary (r = 0.48, P = 0.04), and wake after sleep onset (WASO) (r = 0.49, P = 0.03) and sleep efficiency (r = -0.49, P = 0.03) by actigraphy. In Study 2, right rACC volume was correlated with SOL by diary (r = 0.44, P = 0.05) in PI patients. CONCLUSIONS: Rostral ACC volumes are larger in patients with PI compared with control patients. Clinical severity measures in PI correlate with rACC volumes. These data may reflect a compensatory brain response to chronic insomnia and may represent a marker of resilience to depressive illness.
Keywords: Neuroimaging
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Wortzel HS: A Historical Perspective on Advanced Neuroimaging in Clinics and Courts. Brain Injury Professional 10(3): 18-23, 2013
Abstract not available
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Wortzel HS: Book Review of Clinical Manual of Nueropsychiatry. American Journal of Psychiatry 170(9), 1063-1064, 2013
Abstract not available
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Wortzel HS. The DSM-5 and Forensic Psychiatry. J Psychiatr Pract. 2013 May;19(3):238-41.
In his first Law and Psychiatry column for the Journal of Psychiatric Practice, the author discusses potential forensic consequences of the publication of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). While the transition to DSM-5 may prove challenging for both patients and clinicians, the scrutiny and adversarial process associated with forensic psychiatric practice will entail a unique set of challenges. The philosophy of innovation behind the DSM-5, and the attendant changes, could lead to some unintended consequences, particularly in medicolegal settings. This column highlights some of the major changes in DSM-5 and explores points of particular concern for forensic psychiatric practice, such as the move toward a non-multiaxial diagnostic system and dimensional severity ratings being superimposed on certain categorical diagnoses. The innovative changes featured in DSM-5, and the controversies surrounding some of them, could yield an environment of increased cynicism in courts of law, with renewed skepticism regarding mental health diagnoses and the forensic psychiatrists who testify about them. Fortunately, the best method for forensic psychiatric practice in this environment of change is to continue to adhere to a meticulous and transparent medicolegal process, with recognition that changes in the diagnostic manual will seldom alter essential medicolegal conclusions. Forensic psychiatrists may enhance their credibility and the strength of the opinions they offer by proactively illustrating how nuances in diagnosis do not change legally defined constructs such as insanity or incompetence. (Journal of Psychiatric Practice 2013;19:238-241).
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Wortzel HS, Arciniegas DB: A Forensic Neuropsychiatric Approach to Traumatic Brain Injury, Aggression, and Suicide. Journal of the American Academy of Psychiatry and the Law 41:274-86, 2013
Aggression is a common neuropsychiatric sequela of traumatic brain injury (TBI), one which interferes with rehabilitation efforts, disrupts social support networks, and compromises optimal recovery. Aggressive behavior raises critical safety concerns, potentially placing patients and care providers in harm’s way. Such aggression may be directed outwardly, manifesting as assaultive behavior, or directed inwardly, resulting in suicidal behavior. Given the frequency of TBI and posttraumatic aggression and the potential medicolegal questions surrounding the purported causal relationships between the two, forensic psychiatrists need to understand and recognize posttraumatic aggression. They also must be able to offer cogent formulations about the relative contributions of neurotrauma versus other relevant neuropsychiatric factors versus combinations of both to any specific act of violence. This article reviews the relationships between TBI and aggression and discusses neurobiological and cognitive factors that influence the occurrence and presentation of posttraumatic aggression. Thereafter, a heuristic is offered that may assist forensic psychiatrists attempting to characterize the relationships between TBI and externally or internally directed violent acts.
Keywords: Suicide Prevention, Traumatic Brain Injury (TBI)
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Wortzel HS, Brenner LA, Arciniegas DB. Traumatic Brain Injury and Chronic Traumatic Encephalopathy: A Forensic Neuropsychiatric Perspective. Behav Sci Law. 2013 Sep 9.
Recent scientific reports and popular press describing chronic traumatic encephalopathy (CTE) collectively link this condition to a broad array of neuropsychiatric symptoms, including extremely rare and multi-determined behaviors such as murder-suicide. These reports are difficult to reconcile with several decades of research on the science of traumatic brain injury (TBI) and its consequences, especially the natural history and prognosis of mild TBI. This article attempts to reconcile these sources by reviewing the state of the science on CTE, with particular attention to case definitions and neuropathological criteria for this diagnosis. The evidence for links between TBI, CTE, and catastrophic clinical events is explored, and the complexity of attributing rare frequency behavioral events to CTE is highlighted. The clinical and medicolegal implications of the best available evidence are discussed, concluding with a cautionary note against prematurely generalizing current findings on CTE to entire populations of persons with, or at risk for, concussion exposures. Copyright © 2013 John Wiley & Sons, Ltd.
Keywords: Traumatic Brain Injury (TBI)
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Wortzel HS, Matarazzo B, Homaifar B. A model for therapeutic risk management of the suicidal patient. J Psychiatr Pract. 2013 Jul;19(4):323-6.
While the practice of psychiatry involves many challenges, few scenarios are as clinically and emotionally demanding as managing the patient who is at high risk for suicide. Risk management is a reality of psychiatric practice, and this necessitates practicing and documenting thoughtful suicide risk assessment and management. Therapeutic risk management is based on clinical risk management that is patient-centered, supportive of the treatment process, and maintains the therapeutic alliance. In this article, the authors present a broad overview of a model for achieving therapeutic risk management of the suicidal patient that involves augmenting clinical risk assessment with structured instruments, stratifying risk in terms of both severity and temporality, and developing and documenting a safety plan. These elements are readily accessible to and deployable by mental health clinicians in most disciplines and treatment settings, and they collectively yield a suicide risk assessment and management process (and attendant documentation) that should withstand the scrutiny that often occurs in the wake of a patient suicide or suicide attempt. (Journal of Psychiatric Practice 2013;19:323-326).
Keywords: Suicide Prevention
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Wortzel HS, Shura RD, Brenner LA. Chronic Traumatic Encephalopathy and Suicide: A Systematic Review. Biomed Res Int. 2013;2013:424280. Epub 2013 Nov 17. Review.
Traumatic brain injury (TBI) is a global health concern, and the recent literature reports that a single mild TBI can result in chronic traumatic encephalopathy (CTE). It has been suggested that CTE may lead to death by suicide, raising important prevention, treatment, and policy implications. Thus, we conducted a systematic review of the medical literature to answer the key question: What is the existing evidence in support of a relationship between CTE and suicide? Systematic searches of CTE and suicide yielded 85 unique abstracts. Seven articles were identified for full text review. Only two case series met inclusion criteria and included autopsies from 17 unique cases, 5 of whom died by suicide. Neither studies used blinding, control cases, or systematic data collection regarding TBI exposure and/or medical/neuropsychiatric history. The identified CTE literature revealed divergent opinions regarding neuropathological elements of CTE and heterogeneity regarding clinical manifestations. Overall quality of evidence regarding a relationship between CTE and suicide was rated as very low using Grading of Recommendations Assessment, Development and Evaluation Working Group (GRADE) criteria. Further studies of higher quality and methodological rigor are needed to determine the existence and nature of any relationship between CTE and suicide.
Keywords: Suicide Prevention
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Wortzel HS, Trestman RL: Forensic Neuropsychiatry in Behavioral Neurology & Neuropsychiatry. Edited by Arciniegas DB, Anderson CA, Filley CM. Cambridge, Cambridge University Press, 2013, 406-414
Chapter in book, abstract not available
Keywords: Brain & Biology
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Yamamoto RT, Rohan ML, Goletiani N, Olson D, Peltier M, Renshaw PF, Mello NK. Nicotine related brain activity: the influence of smoking history and blood nicotine levels, an exploratory study. Drug Alcohol Depend. 2013 Apr 1;129(1-2):137-44.
OBJECTIVE: In this study, we sought to explore brain activity in nicotine-dependent men in response to acute intravenous nicotine using pharmacological magnetic resonance imaging (phMRI). METHODS: phMRI was used to evaluate brain activity in response to 1.5 mg/70 kg intravenous nicotine or saline. The nicotine and saline were administered on different visits. The time courses of individual subjects' nicotine levels were used as regressors to assess neural activity relating to the infusions. The influence of smoking history and physiological measures on the response to nicotine were also investigated. RESULTS: Greater lifetime exposure to cigarette smoking was significantly correlated with higher peak serum nicotine levels. PhMRI analysis of the differential response of nicotine compared to the saline condition showed distinctive activation patterns when analyzed with the (a) nicotine time course, (b) nicotine time course controlling for smoking history (pack years), and (c) pack years controlling for nicotine. CONCLUSIONS: These results suggest that smoking exposure history influences serum nicotine levels and the brain's response to nicotine. Alterations in brain activity may be a result of vascular and neuro-adaptations involved in drug exposure and addiction. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.
Keywords: Smoking
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York, J., Lamis, D. A., Friedman, L., Berman, A. L., Joiner, T. E., Mcintosh, J. L., Silverman, M. M., Konick, L., Gutierrez, P. M., & Pearson, J. (2013). A systematic review process to evaluate suicide prevention programs: a sample case of community-based programs. Journal of Community Psychology, 41, 35-51.
Abstract not available
Keywords: Suicide
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Publications - 2012

Bahraini NH, Gutierrez PM, Harwood JEF, Huggins JA, Hedegaard H, Chase M, Brenner LA. (2012). The Colorado Violent Death Reporting System (COVDRS): Validity and Utility of the Veteran Status Variable. Public Health Rep., May/Jun;127(3):304-309.
Objective. Using the Veterans Affairs Beneficiary Identification Record Locator Subsystem (BIRLS) as the criterion database, we evaluated the sensitivity and specificity of the death certificate information in the Colorado Violent Death Reporting System (COVDRS) to determine Veteran status for those who died by suicide. Methods. The study sample consisted of 3,820 individuals aged 18 years and older who died by suicide in Colorado from January 1, 2004, through December 31, 2008. To determine agreement on Veteran status, COVDRS data were submitted to the Veterans Benefits Administration for linkage to the BIRLS using Social Security numbers. Results. Sensitivity and specificity of the Veteran status information on the death certificate were 93.1% (95% confidence interval [CI] 90.7, 95.2) and 91.7% (95% CI 90.5, 92.8), respectively. The overall agreement between the death certificate and the BIRLS on Veteran status was very good (kappa 5 0.76; 95% CI 0.74, 0.79). Conclusions. This study of 3,820 suicide deaths in Colorado demonstrated a high level of agreement between the COVDRS Veteran status variable and the BIRLS. Such findings offer support for using the COVDRS in studying factors associated with suicide in the Veteran population.
Keywords: Suicide Prevention
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Bates MJ, Bradley JC, Bahraini NH, Goldenberg MN. (2012). Clinical Management of Suicide Risk with Military and Veteran Personnel. Chapter in Textbook of Suicide Assessment and Management, 2nd Edition Edited by Simon RI and Hales RE. The American Pyschiatric Publishing, Washington DC, 405-441.
No abstract available
Keywords: Suicide Prevention
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Braden CA, Cuthbert JP, Brenner L, Hawley L, Morey C, Newman J, Staniszewski K, Harrison-Felix C. Health and wellness characteristics of persons with traumatic brain injury. Brain Inj. 2012;26(11):1315-27.
OBJECTIVE: To describe health and wellness characteristics of persons with TBI living in the community, compare to other disability populations and evaluate the associations between health-related constructs. DESIGN: Observational. SETTING: Outpatient rehabilitation hospital and a Veterans Affairs Medical Centre. PARTICIPANTS: Seventy-four community-dwelling adults with moderate-to-severe TBI. INTERVENTIONS: None. MAIN MEASURES: Health Promoting Lifestyle Profile II (HPLP-II), Self Rated Abilities Health Practices Scale (SRAHP), Barriers to Health Promoting Activities for Disabled Scale (BHPAD), Medical Outcomes Study 12-Item Health Status Survey Short Form (SF-12), Personal Resource Questionnaire-adapted (PRQ-a), Perceived Wellness Survey (PWS), Diener Satisfaction with Life Scale (SWLS) and Participation Assessment with Recombined Tools-Objective (PART-O). RESULTS: Health-promoting behaviours, self-efficacy and barriers to health were comparable to other disability populations. Perceived health status, participation and life satisfaction were decreased. Measures of health promotion and self-efficacy were positively associated with perceived mental health status, life satisfaction and participation. Barriers to healthy activities were negatively associated with health promotion, self-efficacy and perceived mental health status. CONCLUSIONS: Health and wellness status was below desired levels for the study cohort, and comparable to other disability populations. Better understanding of associations among health-related constructs is needed. Continued research on conceptually-based health and wellness interventions for persons with TBI is recommended.
Keywords: TBI
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Betthauser LM, Bahraini N, Krengel MH, Brenner LA. Self-Report Measures to Identify Post Traumatic Stress Disorder and/or Mild Traumatic Brain Injury and Associated Symptoms in Military Veterans of Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF). Neuropsychol Rev. 2012 Feb 19.
Individuals serving in Iraq and Afghanistan sustain injuries associated with physical and psychological trauma. Among such injuries, mild traumatic brain injury (mTBI) and post traumatic stress disorder (PTSD) are common. Self-report measures are frequently used to identify mTBI and/or PTSD and symptoms associated with these conditions. In addition to providing information regarding mTBI and PTSD, the goal of this literature review was to identify and present information on the psychometric properties of measures used to obtain information regarding these common conditions among Veterans who have returned from Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF). A comprehensive review of studies in which self-report measures were used to evaluate mTBI, PTSD, and associated symptoms among OEF/OIF Veterans is presented. Findings suggest that additional work is needed to identify psychometrically sound and clinically useful self-report measures that assess mTBI and PTSD and associated symptoms among OEF/OIF Veterans.
Keywords: OEF/OIF/OND, PTSD, Traumatic Brain Injury (TBI)
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Brady RO Jr, Cooper A, Jensen JE, Tandon N, Cohen B, Renshaw P, Keshavan M, Öngür D. A longitudinal pilot proton MRS investigation of the manic and euthymic states of bipolar disorder. Transl Psychiatry. 2012 Sep 11;2:e160.
Several lines of evidence implicate dysfunction in brain energy production as a key component of bipolar disorder. In particular, elevated brain lactate levels observed in this condition suggest a shift from aerobic to anaerobic metabolism, possibly as a result of mitochondrial abnormalities. Most prior imaging studies of brain metabolites were performed in either euthymic or depressed bipolar patients or compared different populations in different mood states. We sought to measure brain metabolite concentrations in the same patients in both manic and euthymic states. Given the dramatic changes in clinical state of bipolar disorder patients, we hypothesized that previously observed abnormalities in lactate concentrations in bipolar disorder might show state dependent changes. In this study 15 patients (mean age 36.1 years) diagnosed with bipolar I disorder underwent proton magnetic resonance spectroscopy of the anterior cingulate cortex and parieto-occipital cortex during hospitalization for acute mania (mean Young Mania Rating Scale (YMRS) 22.1). Seven of these subjects returned (mean interval 21.16 months) to have imaging repeated while euthymic (mean YMRS 2.0). A group of age- and gender-matched control participants (N=6) were scanned as well. We report that during mania, bipolar disorder subjects had lactate levels comparable to healthy control subjects but during euthymia these levels were significantly reduced. No significant change was observed for other metabolites. These results implicate mood dependent alterations in energy metabolism in the biology of bipolar disorder. Additionally, this finding has potential use as a biomarker for both evaluating novel treatments as well as diagnostic clarification between mood disorders.
Keywords: Brain (Neuroanatomy, Neurocognition, Neurotransmitters, etc)
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Brar LG, Wortzel HS, Martinez R. (2012). Mandatory Admission of Guilt in Sex Offender Programs. J Am Acad Psychiatry Law 40:3:433-435.
In 2000, the Pennsylvania General Assembly enacted 42 Pa. Cons. Stat. Ann. § 9718.1 (2001). The statute provides that sex offenders' eligibility for parole is contingent on attending and participating in a Department of Corrections sex offender program. In Newman v. Beard, 617 F.3d 775 (3rd Cir. 2010), the U.S. Court of Appeals for the Third Circuit affirmed a judgment in favor of the defendants: the Pennsylvania Department of Corrections, the Probation and Parole Board of Pennsylvania, and the Sexual Offenders Assessment Board. The court held that the program's requirement for sex offenders to admit guilt to attend did not violate either Mr. Newman's First Amendment and due process rights or the Ex Post Facto Clause of the Constitution.
Keywords: Incarcerated Veterans
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Brenner L, Bahraini N and Hernández TD (2012). Perspectives on creating clinically relevant blast models for mild traumatic brain injury and post traumatic stress disorder symptoms. Front. Neur. 3:31.
Military personnel are returning from Iraq and Afghanistan and reporting non-specific physical (somatic), behavioral, psychological, and cognitive symptoms. Many of these symptoms are frequently associated with mild traumatic brain injury (mTBI) and/or post traumatic stress disorder (PTSD). Despite significant attention and advances in assessment and intervention for these two conditions, challenges persist. To address this, clinically relevant blast models are essential in the full characterization of this type of injury, as well as in the testing and identification of potential treatment strategies. In this publication, existing diagnostic challenges and current treatment practices for mTBI and/or PTSD will be summarized, along with suggestions regarding how what has been learned from existing models of PTSD and traditional mechanism (e.g., non-blast) TBI can be used to facilitate the development of clinically relevant blast models.
Keywords: PTSD, Traumatic Brain Injury (TBI)
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Brenner LA, Barnes SM. (2012). Facilitating Treatment Engagement During High-Risk Transition Periods: A Potential Suicide Prevention Strategy. American Journal of Public Health, Supplement 1, Vol 102, No. S1
Abstract not available
Keywords: Suicide Prevention
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Brenner LA, Braden CA, Bates M, Chase T, Hancock C, Harrison-Felix C, Hawley L, Morey C, Newman J, Pretz C, Staniszewski K. A health and wellness intervention for those with moderate to severe traumatic brain injury: a randomized controlled trial. J Head Trauma Rehabil. 2012 Nov;27(6):E57-68.
OBJECTIVES: To assess the efficacy of a standardized 12-week health and wellness group intervention for those with moderate to severe traumatic brain injury (TBI). STUDY DESIGN: Randomized controlled trial. PARTICIPANTS: Seventy-four individuals with moderate to severe TBI recruited from the outpatient program at a rehabilitation hospital, a Veterans Affairs Medical Center, and the community. METHOD: Eligible participants were randomized to treatment (health and wellness therapy group) or wait-list control (treatment, n = 37; wait-list, n = 37). The primary outcome was the Health Promoting Lifestyle Profile-II. RESULTS: The results of the mixed-model repeated-measures analysis indicated no differences between treatment and control groups engaging in activities to increase their health and well-being. CONCLUSIONS: Findings did not support the efficacy of the intervention. Results may have been impacted by the wide variability of individualized health and wellness goals selected by group members, the structure and/or content of the group, and/or the outcome measures selected.
Keywords: Traumatic Brain Injury (TBI)
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Bryan, C.J., Clemans, T.A., & Hernández, A.M. (2012). Perceived burdensomeness, fearlessness of death, and suicidality among deployed military personnel. Personality and Individual Differences, 52, 374-379.
Abstract: The interpersonal-psychological theory of suicide posits that the interaction of three elements is required for lethal suicidal behaviors: the perception that one is a burden on others, the perception that one does not belong, and fearlessness about death combined with high pain tolerance (termed "acquired capability" for suicide). Although an ever expanding research base supports the theory, very limited data exist supporting the theory among military personnel, a group that has experienced a rapid increase in suicides during the past several years. The current study tests the interpersonal-psychological theory in two clinical samples of military personnel while deployed to Iraq: those seeking treatment for mild traumatic brain injury, and those seeking outpatient mental health treatment. In both samples, perceived burdensomeness and acquired capability were significantly associated with suicidality, as was their interaction term. Results partially support the interpersonal-psychological theory of suicide, and indicate that perceptions of burdensomeness combined with fearlessness about death are associated with increased suicidality among deployed military personnel.
Keywords: Suicide Prevention
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Churchwell JC, Carey PD, Ferrett HL, Stein DJ, Yurgelun-Todd DA. Abnormal striatal circuitry and intensified novelty seeking among adolescents who abuse methamphetamine and cannabis. Dev Neurosci. 2012;34(4):310-7.
It has been hypothesized that changes in striatal-mediated dopamine modulation during adolescence may increase the risk for initiating substance abuse as a result of its fundamental role in arbitrating reward sensitivity and motivation during learning and decision making. However, substance abuse during adolescence may also significantly modify striatal structure and function and concomitantly alter reward sensitivity and action control while this brain region is undergoing remodeling. In the present investigation, to assess the relationship of methamphetamine (Meth) or Meth and cannabis (CA) abuse to regional striatal morphology, we acquired structural magnetic resonance images, using a 3T Siemens Trio scanner, from three groups of adolescents composed of healthy controls (n = 10), Meth abusers (n = 9) and combined Meth and CA abusers (Meth+CA, n = 8). We also assessed novelty seeking using the novelty seeking subscale of Cloninger's Tridimensional Character Inventory. The results indicate that adolescent Meth+CA abusers have increased regional striatal volume and show intensified novelty seeking in contrast to the controls. The degree of Meth exposure was also positively correlated with regional striatal volume and novelty seeking in both the Meth and Meth+CA users. These preliminary findings support theories that propose a role for the striatum in adolescent substance abuse and further indicate that novelty seeking may be related to the initiation of, or sustained, drug use.
Keywords: Substance Abuse
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Gutierrez PM, Freedenthal S, Wong JL, Osman A, Norizuki T. Validation of the Suicide Resilience Inventory-25 (SRI-25) in Adolescent Psychiatric Inpatient Samples. J Pers Assess. (2012) Jan;94(1):53-61.
Resilience has been associated with a markedly decreased chance for risky behaviors following a trauma or other negative life event. This study examined the factor structure and psychometric properties of a self-report measure of resilience, the Suicide Resilience Inventory-25 (SRI-25; Osman et al., 2004 ), among psychiatric inpatient adolescents. In Study 1, we conducted confirmatory factor analysis to provide additional empirical support for the structure and invariance of the 3-factor model of the SRI-25 in youth samples, ages 14 to 17 years (N = 152 boys, 220 girls). Scale reliability analyses provided good evidence for internal consistency reliability of scores on the SRI-25 total and scales. In Study 2 (N = 30 boys, 40 girls), we presented data in support for the concurrent validity (i.e., known groups) of scores on the SRI-25. Additionally, we identified potential correlates for the SRI-25 total scale scores.
Keywords: Suicide Prevention
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Hart T, Hoffman JM, Pretz C, Kennedy R, Clark AN, Brenner LA. (2012). A Longitudinal Study of Major and Minor Depression Following Traumatic Brain Injury. Archives of Physical Medicine, 93, 1343-9.
OBJECTIVE: To examine patterns of change and factors associated with change in depression, both major (major depressive disorder [MDD]) and minor, between 1 and 2 years after traumatic brain injury (TBI). DESIGN: Observational prospective longitudinal study. SETTING: Inpatient rehabilitation centers, with 1- and 2-year follow-up conducted primarily by telephone. PARTICIPANTS: Persons with TBI (N=1089) enrolled in the Traumatic Brain Injury Model Systems database, followed at 1 and 2 years postinjury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Patient Health Questionnaire-9. RESULTS: Among participants not depressed at 1 year, close to three fourths remained so at 2-year follow-up. However, 26% developed MDD or minor depression between the first and second years postinjury. Over half of participants with MDD at year 1 also reported MDD the following year, with another 22% reporting minor depression; thus three fourths of those with MDD at year 1 experienced clinically significant symptoms at year 2. Almost one third of those with minor depression at year 1 traversed to MDD at year 2. Polytomous logistic regression confirmed that worse depression at year 1 was associated with higher odds of depression a year later. For those without depression at year 1, symptom worsening over time was related to year 2 problematic substance use and lower FIM motor and cognitive scores. For those with depression at year 1, worsening was associated with lower cognitive FIM, poor social support, and preinjury mental health issues including substance abuse. CONCLUSIONS: Major and minor depression exist on a continuum along which individuals with TBI may traverse over time. Predictors of change differ according to symptom onset. Results highlight importance of long-term monitoring for depression, treating minor as well as major depression, and developing interventions for comorbid depression and substance abuse.
Keywords: Traumatic Brain Injury (TBI), Seriously Mentally Ill (SMI)
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Homaifar, B. Y., Bahraini, N.H., Silverman, M.M., Brenner, L.A.. (2012). Executive Functioning as a Component of Suicide Risk Assessment: Clarifying its Role in Standard Clinical Applications. Journal of Mental Health Counseling, 34(2), 110-120.
Clinically, because executive dysfunction (e.g., impulsivity, insight, thinking process) is often thought of in the context of those with traumatic brain injuries and other neurologic conditions, its formal assessment has historically been seen as the domain of those who assess and treat patients with neurologic disease. However, mental health counselors (MHCs) could benefit from learning how executive functioning relates to suicide risk assessment and coping strategies. Assessment of executive functions can be incorporated in routine clinical practice without the need for formal neuropsychological measures or other time-consuming procedures. In fact, during standard clinical assessment, mental health professionals often informally assess components of executive functioning such as impulsivity, insight, and thinking processes. This article highlights aspects of executive functioning with which MHCs may already be familiar and demonstrates their clinical utility in enhancing assessment and management of suicide-related thoughts and behaviors.
Keywords: Assessment, Suicide Prevention, Traumatic Brain Injury (TBI)
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Homaifar BY, Brenner LA, Forster JE, Nagamoto H. Traumatic brain injury, executive functioning, and suicidal behavior: A brief report. Rehabil Psychol. 2012 Nov;57(4):337-41.
Objective: The aim of this pilot study was to explore the relationship between executive dysfunction and suicidal behavior in two groups of participants: (Group 1, n = 18) veterans with traumatic brain injury (TBI) and a history of at least one suicide attempt (SA), and (Group 2, n = 29) veterans with TBI and no history of SA. Controlling for the severity of TBI, it was hypothesized that participants in Group 1 would perform more poorly than those in Group 2 on measures of executive functioning. Design: The primary outcome variable was decision making as assessed by performance on the Iowa Gambling Task (IGT). Secondary outcome variables included laboratory-measured impulsivity as measured by the Immediate and Delayed Memory Test (IMT/DMT), abstract reasoning as measured by the Wisconsin Card Sorting Test (WCST), and aggression as measured by the Lifetime History of Aggression (LHA) scale. Results: Among those in Group 1, time between TBI and first suicide attempt postinjury varied widely (months to nearly 30 years). Only the WCST perseverative errors score differed significantly between individuals with and without histories of one or more suicide attempts (SAs). Conclusion: Suggestions for future study of SA among those with TBI are provided. When working with individuals with TBI, clinicians are encouraged to incorporate suicide risk assessment into their practice. Augmenting this process with a measure of perseveration may be beneficial. (PsycINFO Database Record (c) 2012 APA, all rights reserved).
Keywords: Assessment, Suicide Prevention, Traumatic Brain Injury (TBI)
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Knox KL, Stanley B, Currier GW, Brenner LA, Ghahramanlou-Holloway M, Brown GK. An emergency based brief intervention for veterans at risk for suicide (SAFE VET). Am J Public Health. 2012;102(S1):S33 – S37.
Reducing deaths from veteran suicide is a public health priority for veterans who receive their care from the Department of Veterans Affairs (VA) and those who receive services in community settings. Emergency departments frequently function as the primary or sole point of contact with the health care system for suicidal individuals; therefore, they represent an important venue in which to identify and treat veterans who are at risk for suicide. We describe the design, implementation and initial evaluation of a brief behavioral intervention for suicidal veterans seeking care at VA emergency departments. Initial findings of the feasibility and acceptability of the intervention suggest it may be transferable to diverse VA and non-VA settings, including community emergency departments and urgent care centers.
Keywords: Suicide Prevention
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Kwentus J, Riesenberg RA, Marandi M, Manning RA, Allen MH, Fishman RS, Spyker DA, Kehne JH, Cassella JV. Rapid acute treatment of agitation in patients with bipolar I disorder: a multicenter, randomized, placebo-controlled clinical trial with inhaled loxapine. Bipolar Disord. 2012 Feb;14(1):31-40.
Kwentus J, Riesenberg RA, Marandi M, Manning RA, Allen MH, Fishman RS, Spyker DA, Kehne JH, Cassella JV. Rapid acute treatment of agitation in patients with bipolar I disorder: a multicenter, randomized, placebo-controlled clinical trial with inhaled loxapine. Bipolar Disord 2012: 14: 31-40. © 2012 The Authors. Journal compilation © 2012 John Wiley & Sons A/S. Objective: The present study evaluated inhaled loxapine for the acute treatment of agitation in patients with bipolar I disorder. Methods: A Phase 3, randomized, double blind, placebo-controlled, parallel group inpatient study was performed at 17 psychiatric research facilities. Agitated patients (N=314) with bipolar I disorder (manic or mixed episodes) were randomized (1:1:1) to inhaled loxapine 5mg or 10mg, or inhaled placebo using the Staccato(®) system. Following baseline assessments, patients received Dose 1 and were evaluated for 24hours. If required, up to two additional doses of study drug and/or lorazepam rescue medication were given. The primary efficacy endpoint was change from baseline in the Positive and Negative Syndrome Scale-Excited Component (PANSS-EC) score two hours after Dose 1. The key secondary endpoint was the Clinical Global Impression-Improvement score at two hours after Dose 1. Additional endpoints included the changes from baseline in the PANSS-EC from 10min through 24hours after Dose 1. Safety was assessed by adverse events, vital signs, physical examinations, and laboratory tests. Results: For the primary and key secondary endpoints, both doses of inhaled loxapine significantly reduced agitation compared with placebo. Reduced agitation, as reflected in PANSS-EC score, was evident 10min after Dose 1 with both doses. Inhaled loxapine was well tolerated, and the most common adverse events were known effects of loxapine or minor oral effects common with inhaled medications (dysgeusia was reported in 17% of patients receiving active drug versus 6% receiving placebo). Conclusions: Inhaled loxapine provided a rapid, non-injection, well-tolerated acute treatment for agitation in patients with bipolar I disorder.
Keywords: Seriously Mentally Ill (SMI)
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Lopez-Larson MP, King JB, Terry J, McGlade EC, Yurgelun-Todd D. Reduced insular volume in attention deficit hyperactivity disorder. Psychiatry Res. 2012 Oct 30;204(1):32-9.
The aim of this study was to evaluate whether structural differences in the insula and anterior cingulate cortex (ACC), two critical areas of the "salience network," co-exist in adolescents with attention deficit hyperactivity disorder (ADHD) compared with healthy controls (HC). In addition we aimed to determine if structural changes within these regions correlate with attention and inhibitory function. Nineteen adolescents with ADHD and 25 HC received MRI scans on a 3T magnet. Morphometric analysis was performed with FreeSurfer. Youths with ADHD were found to have a bilateral reduction in anterior insular (AIC) gray matter volumes compared to HC. Furthermore, the left AIC was found to positively correlate with oppositional symptoms, while the right AIC was found to associate with both attention problems and inhibition. To our knowledge this is the first report of a bilateral reduction in AIC volumes in ADHD. Our findings suggest a role for the insula in modulating attention and inhibitory capacity in ADHD. Published by Elsevier Ireland Ltd.
Keywords: Mood Disorders
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Lopez-Larson MP, Rogowska J, Bogorodzki P, Bueler CE, McGlade EC, Yurgelun-Todd DA. Cortico-cerebellar abnormalities in adolescents with heavy marijuana use. Psychiatry Res. 2012 Jun 30;202(3):224-32.
here are currently no studies that have evaluated the motor network, including the cerebellum, in adolescent marijuana (MJ) smokers. The current study aimed to evaluate whether there were activation differences in Brodmann's area 4 (BA4), Brodmann's area 6 (BA6), cingulate (CG) and cerebellum between MJ-using adolescents and healthy controls (HC) on a functional magnetic resonance imaging (fMRI) bilateral finger-tapping task. Twenty-four adolescents (aged 18.2 ± 0.7 years) with heavy MJ use and 24 HC (18.0 ± 1.9) had MRI scans on a 3T Siemens scanner, including a standard bilateral fMRI finger-tapping sequence. Imaging data were analyzed using SPM5 in Matlab. As regions of interest, BA4, BA6, cingulate (CG) and cerebellum were selected, and significant clusters of activity were thresholded at p<0.05, corrected. Healthy controls had significantly greater activation than MJ users for the CG and cerebellum. In addition, activation of the cerebellum and CG correlated with lifetime MJ smokes. This is one of the first studies to evaluate cortico-cerebellar circuits in adolescents with heavy MJ use. The study, which used a bilateral finger-tapping fMRI task, provides evidence for both CG and cerebellar dysfunction in MJ abuse and indicates that lifetime MJ use may impact the developing brain. Published by Elsevier Ireland Ltd.
Keywords: Substance Abuse
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Lyoo IK, Yoon S, Jacobson AM, Hwang J, Musen G, Kim JE, Simonson DC, Bae S, Bolo N, Kim DJ, Weinger K, Lee JH, Ryan CM, Renshaw PF. Prefrontal cortical deficits in type 1 diabetes mellitus: brain correlates of comorbid depression. Arch Gen Psychiatry. 2012 Dec;69(12):1267-76.
CONTEXT Neural substrates that may be responsible for the high prevalence of depression in type 1 diabetes mellitus (T1DM) have not yet been elucidated. OBJECTIVE To investigate neuroanatomic correlates of depression in T1DM. DESIGN Case-control study using high-resolution brain magnetic resonance images. SETTINGS Joslin Diabetes Center and McLean Hospital, Massachusetts, and Seoul National University Hospital, South Korea. PARTICIPANTS A total of 125 patients with T1DM (44 subjects with ≥1 previous depressive episodes [T1DM-depression group] and 81 subjects who had never experienced depressive episodes [T1DM-only group]), 23 subjects without T1DM but with 1 or more previous depressive episodes (depression group), and 38 healthy subjects (control group). MAIN OUTCOME MEASURES Spatial distributions of cortical thickness for each diagnostic group were compared with the control group using a surface-based approach. Among patients with T1DM, associations between metabolic control measures and cortical thickness deficits were examined. RESULTS Thickness reduction in the bilateral superior prefrontal cortical regions was observed in the T1DM-depression, T1DM-only, and depression groups relative to the control group at corrected P < .01. Conjunction analyses demonstrated that thickness reductions related to the influence of T1DM and those related to past depressive episode influence were observed primarily in the superior prefrontal cortical region. Long-term glycemic control levels were associated with superior prefrontal cortical deficits in patients with T1DM (β = -0.19, P = .02). CONCLUSIONS This study provides evidence that thickness reduction of prefrontal cortical regions in patients with T1DM, as modified by long-term glycemic control, could contribute to the increased risk for comorbid depression.
Keywords: Depression
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Lyoo IK, Yoon S, Kim TS, Hwang J, Kim JE, Won W, Bae S, Renshaw PF. A Randomized, Double-Blind Placebo-Controlled Trial of Oral Creatine Monohydrate Augmentation for Enhanced Response to a Selective Serotonin Reuptake Inhibitor in Women With Major Depressive Disorder. Am J Psychiatry. 2012 Aug 1. doi: 10.1176/appi.ajp.2012.12010009. [Epub ahead of print]
OBJECTIVE Antidepressants targeting monoaminergic neurotransmitter systems, despite their immediate effects at the synaptic level, usually require several weeks of administration to achieve clinical efficacy. The authors propose a strategy of adding creatine monohydrate (creatine) to a selective serotonin reuptake inhibitor (SSRI) in the treatment of patients with major depressive disorder. Such augmentation may lead to a more rapid onset of antidepressant effects and a greater treatment response, potentially by restoring brain bioenergetics at the cellular level. METHOD Fifty-two women with major depressive disorder were enrolled in an 8-week double-blind placebo-controlled clinical trial and randomly assigned to receive escitalopram in addition to either creatine (5 g/day, N=25) or placebo (N=27). Efficacy was primarily assessed by changes in the Hamilton Depression Rating Scale (HAM-D) score. RESULTS In comparison to the placebo augmentation group, patients receiving creatine augmentation showed significantly greater improvements in HAM-D score, as early as week 2 of treatment. This differential improvement favoring creatine was maintained at weeks 4 and 8. There were no differences between treatment groups in the proportion of patients who discontinued treatment prematurely (creatine: N=8, 32.0%; placebo: N=5, 18.5%) or in the overall frequency of all reported adverse events (creatine: 36 events; placebo: 45 events). CONCLUSIONS The current study suggests that creatine augmentation of SSRI treatment may be a promising therapeutic approach that exhibits more rapid and efficacious responses in women with major depressive disorder.
Keywords: Brain & Biology, Seriously Mentally Ill (SMI)
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Matarazzo BB. Adaptive institutional transference in the treatment of individuals with borderline personality disorder. Bull Menninger Clin. 2012 Fall;76(4):297-313.
The author introduces "adaptive institutional transference" (AIT) and describes how it develops in some patients in response to psychotherapist transfer in psychology training clinics. Individuals with borderline personality disorder are especially likely to develop AIT because of difficulties related to abandonment depression. Directors, supervisors, and student psychotherapists in a variety of training settings should be aware of these dynamics because of their important treatment implications, which are described. Limitations and ideas for future exploratory and qualitative research are also discussed.
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Matarazzo BB, Clemans TA, Silverman MM, Brenner LA. The Self-Directed Violence Classification System and the Columbia Classification Algorithm for Suicide Assessment: A Crosswalk. Suicide Life Threat Behav. 2012 Nov 12.
The lack of a standardized nomenclature for suicide-related thoughts and behaviors prompted the Centers for Disease Control and Prevention, with the Veterans Integrated Service Network 19 Mental Illness Research Education and Clinical Center, to create the Self-Directed Violence Classification System (SDVCS). SDVCS has been adopted by the Department of Veterans Affairs and the Department of Defense. Another classification system, the Columbia Classification Algorithm for Suicide Assessment, has been recommended by the Food and Drug Administration. To facilitate the use of both systems, this article provides a "crosswalk" between the two classification systems. © 2012 The American Association of Suicidology.
Keywords: Suicide Prevention
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Matthews EE, Schmiege SJ, Cook PF, Berger AM, Aloia MS. Adherence to cognitive behavioral therapy for insomnia (CBTI) among women following primary breast cancer treatment: a pilot study. Behav Sleep Med. 2012;10(3):217-29.
Cognitive behavioral therapy for insomnia (CBTI) has proven efficacy, yet 32%-89% of patients fail to consistently follow recommendations. This pilot study examines adherence to CBTI in breast cancer survivors with insomnia. There was a significant decline in adherence to prescribed rise time, and total time in bed, but no change in adherence to prescribed bedtime during six weekly sessions. Factors associated with higher adherence included lower fatigue and higher baseline motivation. Higher adherence was associated with worse subjective sleep quality at the beginning of CBTI and fewer nocturnal awakenings at the end of treatment. Results provide preliminary evidence supporting the impact of adherence on sleep outcomes such as fewer nocturnal awakenings. Attention to adherence as part of CBTI may yield greater sleep improvements.
Keywords: Sleep
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McChargue DE, Sankaranarayanan J, Visovsky CG, Matthews EE, Highland KB, Berger AM. Predictors of adherence to a behavioral therapy sleep intervention during breast cancer chemotherapy. Support Care Cancer. 2012 Feb;20(2):245-52.
BACKGROUND: This study's purpose was twofold: (1) to establish adherence rates to a behavioral therapy (BT) sleep intervention and (2) to identify psychological and physical symptom predictors of adherence to the intervention in women undergoing breast cancer chemotherapy. METHODS: A randomized controlled trial began 48 h before the first of four chemotherapy treatments. Women with stages I-IIIA breast cancer (n = 113) received a BT sleep intervention composed of stimulus control, modified sleep restriction (MSR), relaxation therapy (RT), and sleep hygiene counseling components. A BT plan was developed by a research nurse and each participant, reinforced on day 8, and repeated for chemotherapy cycles 2, 3, and 4. Adherence to the BT plan was measured daily; total adherence score was computed at each chemotherapy cycle by combining adherence estimates of all BT plan components. Psychological and physical symptoms over the past 7 days were measured 2 days prior to and 7 days after each chemotherapy treatment. RESULTS: Total adherence rates to the BT plan were 51-52% at all four treatments but adherence varied by component. Sleep disturbance, pain, and anxiety significantly decreased whereas depression significantly increased across chemotherapy. Structural equation modeling revealed a good model fit with decreasing sleep disturbances (0.409) and increasing depression (-0.711) contributing to lower total adherence rates. Increasing depression predicted lower MSR adherence (-0.203) and decreasing sleep disturbances predicted lower RT adherence (1.220). CONCLUSIONS: Sleep disturbance and depression significantly impacted adherence rates during chemotherapy. Results warrant attention when promoting adherence to BT sleep interventions during chemotherapy treatment.
Keywords: Sleep
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McGlade, E., Locatelli, A., Hardy, J., Kamiya, T., Morita, M., Morishita, K., Sugimura, Y., & Yurgelun-Todd, D. (2012). Improved attentional performance following citicoline administration in healthy women. Food and Nutrition Sciences, 3(6), 769-773.
Abstract not available
Keywords: Women
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Olson-Madden J, Brenner LA, Corrigan JD, Emrick CD, Britton PC. (2012). "Substance Use and Mild Traumatic Brain Injury Risk Reduction and Prevention: A Novel Model for Treatment," Rehabilitation Research and Practice, vol. 2012, Article ID 174579, 6 pages, 2012. doi:10.1155/2012/174579.
Traumatic brain injury (TBI) and substance use disorders (SUDs) frequently co-occur. Individuals with histories of alcohol or other drug use are at greater risk for sustaining TBI, and individuals with TBI frequently misuse substances before and after injury. Further, a growing body of literature supports the relationship between comorbid histories of mild TBI (mTBI) and SUDs and negative outcomes. Alcohol and other drug use are strongly associated with risk taking. Disinhibition, impaired executive function, and/or impulsivity as a result of mTBI also contribute to an individual’s proclivity towards risk-taking. Risk-taking behavior may therefore, be a direct result of SUD and/or history of mTBI, and risky behaviors may predispose individuals for subsequent injury or continued use of substances. Based on these findings, evaluation of risk-taking behavior associated with the co-occurrence of SUD and mTBI should be a standard clinical practice. Interventions aimed at reducing risky behavior among members of this population may assist in decreasing negative outcomes. A novel intervention (Substance Use and Traumatic Brain Injury Risk Reduction and Prevention (STRRP)) for reducing and preventing risky behaviors among individuals with co-occurring mTBI and SUD is presented. Areas for further research are discussed.
Keywords: Evidence Based Treatment, Substance Use Disorders (SUD), Traumatic Brain Injury (TBI)
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Olson-Madden J, Forster JE, Huggins J, Schneider A. (2012). Psychiatric Diagnoses, Mental Health Utilization, High-Risk Behaviors, and Self-Directed Violence Among Veterans With Comorbid History of Traumatic Brain Injury and Substance Use Disorders. Journal of Head Trauma Rehabilitation. Volume 27(5), September/October 2012, p 370–378
Objectives: To describe various characteristics of veterans with co-occurring histories of traumatic brain injury (TBI) and substance use disorder (SUD) for purposes of hypothesis generation. Study Design: Archival data collected over a period of 4 years. Participants: Sixty-five veterans across eras of service with confirmed histories of TBI and SUD. Methods: Demographic and TBI information were obtained from an archival clinical database. Electronic medical records were reviewed for mental health utilization, psychiatric diagnoses, self-directed violence, and risk-taking behaviors. Results: In addition to a SUD, veterans were reported to have an average of 3 additional psychiatric diagnoses and a median of 3 TBIs per person. All utilized various mental health services in addition to substance use treatment. Individuals were found to have engaged in a variety of risky behaviors. There were significant associations between suicidal ideation and assaultive behaviors, as well as between suicide attempt and impulsivity. Conclusions: This study describes a sample of veterans with co-occurring histories of TBI, SUD, risk-taking behaviors, and self-directed violence. More research is needed to examine these complex interrelationships and to identify specific risk factors for intervention/prevention strategies.
Keywords: Traumatic Brain Injury (TBI), Substance Use Disorders (SUD)
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Osman A, Wong JL, Bagge CL, Freedenthal S, Gutierrez PM, Lozano G. The Depression Anxiety Stress Scales-21 (DASS-21): Further Examination of Dimensions, Scale Reliability, and Correlates. J Clin Psychol. 2012 Dec;68(12):1322-38.
OBJECTIVES: We conducted two studies to examine the dimensions, internal consistency reliability estimates, and potential correlates of the Depression Anxiety Stress Scales-21 (DASS-21; Lovibond & Lovibond, 1995). METHOD: Participants in Study 1 included 887 undergraduate students (363 men and 524 women, aged 18 to 35 years; mean [M] age = 19.46, standard deviation [SD] = 2.17) recruited from two public universities to assess the specificity of the individual DASS-21 items and to evaluate estimates of internal consistency reliability. Participants in a follow-up study (Study 2) included 410 students (168 men and 242 women, aged 18 to 47 years; M age = 19.65, SD = 2.88) recruited from the same universities to further assess factorial validity and to evaluate potential correlates of the original DASS-21 total and scale scores. RESULTS: Item bifactor and confirmatory factor analyses revealed that a general factor accounted for the greatest proportion of common variance in the DASS-21 item scores (Study 1). In Study 2, the fit statistics showed good fit for the bifactor model. In addition, the DASS-21 total scale score correlated more highly with scores on a measure of mixed depression and anxiety than with scores on the proposed specific scales of depression or anxiety. Coefficient omega estimates for the DASS-21 scale scores were good. CONCLUSIONS: Further investigations of the bifactor structure and psychometric properties of the DASS-21, specifically its incremental and discriminant validity, using known clinical groups are needed.
Keywords: Assessment, Evidence Based Treatment, Seriously Mentally Ill (SMI)
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Prescot AP, Richards T, Dager SR, Choi C, Renshaw PF. Phase-adjusted echo time (PATE)-averaging 1 H MRS: application for improved glutamine quantification at 2.89 T. NMR Biomed. 2012 Nov;25(11):1245-52.
(1) H MRS investigations have reported altered glutamatergic neurotransmission in a variety of psychiatric disorders. The unraveling of glutamate from glutamine resonances is crucial for the interpretation of these observations, although this remains a challenge at clinical static magnetic field strengths. Glutamate resolution can be improved through an approach known as echo time (TE) averaging, which involves the acquisition and subsequent averaging of multiple TE steps. The process of TE averaging retains the central component of the glutamate methylene multiplet at 2.35 ppm, with the simultaneous attenuation of overlapping phase-modulated coupled resonances of glutamine and N-acetylaspartate. We have developed a novel post-processing approach, termed phase-adjusted echo time (PATE) averaging, for the retrieval of glutamine signals from a TE-averaged (1) H MRS dataset. The method works by the application of an optimal TE-specific phase term, which is derived from spectral simulation, prior to averaging over TE space. The simulation procedures and preliminary in vivo spectra acquired from the human frontal lobe at 2.89 T are presented. Three metabolite normalization schemes were developed to evaluate the frontal lobe test-retest reliability for glutamine measurement in six subjects, and the resulting values were comparable with previous reports for within-subject (9-14%) and inter-subject (14-20%) measures. Using the acquisition parameters and TE range described, glutamine quantification is possible in approximately 10 min. The post-processing methods described can also be applied retrospectively to extract glutamine and glutamate levels from previously acquired TE-averaged (1) H MRS datasets. Copyright © 2012 John Wiley & Sons, Ltd.
Keywords: Brain (Neuroanatomy, Neurocognition, Neurotransmitters, etc)
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Ribeiro JD, Pease JL, Gutierrez PM, Silva C, Bernert RA, Rudd MD, Joiner TE Jr. Sleep problems outperform depression and hopelessness as cross-sectional and longitudinal predictors of suicidal ideation and behavior in young adults in the military. J Affect Disord. 2012 Feb;136(3):743-50.
Background: Sleep problems appear to represent an underappreciated and important warning sign and risk factor for suicidal behaviors. Given past research indicating that disturbed sleep may confer such risk independent of depressed mood, in the present report we compared self-reported insomnia symptoms to several more traditional, well-established suicide risk factors: depression severity, hopelessness, PTSD diagnosis, as well as anxiety, drug abuse, and alcohol abuse symptoms.
Methods: Using multiple regression, we examined the cross-sectional and longitudinal relationships between insomnia symptoms and suicidal ideation and behavior, controlling for depressive symptom severity, hopelessness, PTSD diagnosis, anxiety symptoms, and drug and alcohol abuse symptoms in a sample of military personnel (N=311).
Results: In support of a priori hypotheses, self-reported insomnia symptoms were crosssectionally associated with suicidal ideation, even after accounting for symptoms of depression, hopelessness, PTSD diagnosis, anxiety symptoms and drug and alcohol abuse. Selfreported insomnia symptoms also predicted suicide attempts prospectively at one-month follow up at the level of a non-significant trend, when controlling for baseline self-reported insomnia symptoms, depression, hopelessness, PTSD diagnosis and anxiety, drug and alcohol abuse symptoms. Insomnia symptoms were unique predictors of suicide attempt longitudinally when only baseline self-reported insomnia symptoms, depressive symptoms and hopelessness were controlled.
Limitations: The assessment of insomnia symptoms consisted of only three self-report items. Findings may not generalize outside of populations at severe suicide risk. Conclusions: These findings suggest that insomnia symptoms may be an important target for suicide risk assessment and the treatment development of interventions to prevent suicide.
Keywords: Suicide Prevention, PTSD, Substance Use Disorders (SUD) 
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Rings JA, Alexander PA, Silvers VN, Gutierrez PM. (2012). Adapting the Safety Planning Intervention for Use in a Veterans Psychiatric Inpatient Group Setting. Journal of Mental Health Counseling, 34(2), 95-109.
The Department of Veterans Affairs (VA) recently has adopted the Safety Planning Intervention (SPI; Stanley & Brown, 2011), a brief collaborative intervention, for use with veterans who are at high risk of suicide. The SPI is a hierarchical list of strategies for veterans to use in coping with a suicidal crisis. Its developers recommended that it be used with individual psychiatric inpatients working toward discharge, but its utility in a group format has not previously been addressed. This article describes the facilitation of a safety planning group with psychiatric inpatients at a large urban VA medical center. It depicts each step in the safety plan and offers case examples, anecdotal support, and specific considerations for its use in groups. Directions for further research are also discussed.
Keywords: Assessment, Suicide Prevention
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Schmitz WM Jr, Allen MH, Feldman BN, Gutin NJ, Jahn DR, Kleespies PM, Quinnett P, Simpson S. Preventing Suicide through Improved Training in Suicide Risk Assessment and Care: An American Association of Suicidology Task Force Report Addressing Serious Gaps in U.S. Mental Health Training. Suicide Life Threat Behav. 2012 Jun;42(3):292-304. doi: 10.1111/j.1943-278X.2012.00090.x. Epub 2012 Apr 11.
There are twice as many suicides as homicides in the United States, and the suicide rate is rising. Suicides increased 12% between 1999 and 2009. Mental health professionals often treat suicidal patients, and suicide occurs even among patients who are seeking treatment or are currently in treatment. Despite these facts, training of most mental health professionals in the assessment and management of suicidal patients is surprisingly limited. The extant literature regarding the frequency with which mental health professionals encounter suicidal patients is reviewed, as is the prevalence of training in suicide risk assessment and management. Most importantly, six recommendations are made to address the longstanding insufficient training within the mental health professions regarding the assessment and management of suicidal patients.
Keywords: Assessment, Suicide Prevention
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Walter KH, Barnes SM, Chard KM. The influence of comorbid MDD on outcome after residential treatment for veterans with PTSD and a history of TBI. J Trauma Stress. 2012 Aug;25(4):426-32. doi: 10.1002/jts.21722. Epub 2012 Jul 20.
Among military personnel, posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and a history of traumatic brain injury (TBI) are frequently reported, highlighting the need for treatment outcome research with this population. This study examined the influence of the presence or absence of comorbid MDD on the outcome of a residential treatment program at the midpoint and end of the program for 47 male veterans with PTSD and a history of TBI. Results demonstrated significant decreases of self-reported symptoms on the PTSD Checklist-Stressor Specific Version (PCL-S; MDD, d = 1.19; No MDD, d = 1.17) and the Beck Depression Inventory-II (BDI-II; MDD, d = 0.98; No MDD, d = 1.09) following treatment for both groups. There were no differences in the rate of symptom reduction between groups. Individuals who also met criteria for MDD at pretreatment, however, evidenced higher scores on symptom measures at all assessment time points (ds = 0.60-1.25). Copyright © 2012 International Society for Traumatic Stress Studies.
Keywords: PTSD, Traumatic Brain Injury (TBI)
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Westmoreland P, Wortzel HS, Martinez R. (2012). Federal District Court’s Ordering of Multiple Competency Examinations. J Am Acad Psychiatry Law 40:3:437-439
In United States v. Martinez-Haro, 645 F.3d 1228 (10th Cir. 2011), the United States Court of Appeals for the Tenth Circuit affirmed a federal district court decision to order additional psychological testing to determine the trial competency of a Spanish-speaking defendant, over his objection.
Keywords: Incarcerated Veterans
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Wheeler A, Wortzel HS, Martinez R. (2012). Required Sex Offender Treatment and Due Process Rights. J Am Acad Psychiatry Law 40:3:435-437.
In Dykstra v. Iowa, 783 N.W.2d 473 (2010), the Supreme Court of Iowa ruled that Iowa's Department of Corrections (IDOC) procedural implementation of Iowa Code § 903A.2 (1) (a) (Supp. 2005), which states that “an inmate required to participate in sex offender treatment program” (SOTP) will not be eligible for a reduced sentence unless the inmate participates and completes such a program, violated due process rights because of the lack of procedural protections as outlined in Wolff v. McDonnell, 418 U.S. 539 (1974).
Keywords: Incarcerated Veterans
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Wortzel HS, Arciniegas DB. Treatment of Post-Traumatic Cognitive Impairments. Curr Treat Options Neurol. 2012 Aug 7. [Epub ahead of print]
OPINION STATEMENT: Cognitive impairment is a common consequence of traumatic brain injury (TBI) and a substantial source of disability. Across all levels of TBI severity, attention, processing speed, episodic memory, and executive function are most commonly affected. The differential diagnosis for post-traumatic cognitive impairments is broad, and includes emotional, behavioral, and physical problems as well as substance use disorders, medical conditions, prescribed and self-administered medications, and symptom elaboration. Thorough neuropsychiatric assessment for such problems is a prerequisite to treatments specifically targeting cognitive impairments. First-line treatments for post-traumatic cognitive impairments are nonpharmacologic, including education, realistic expectation setting, environmental and lifestyle modifications, and cognitive rehabilitation. Pharmacotherapies for post-traumatic cognitive impairments include uncompetitive N-methyl-D-aspartate receptor (NMDA) antagonists, medications that directly or indirectly augment cerebral catecholaminergic or acetylcholinergic function, or agents with combinations of these properties. In the immediate post-injury period, treatment with uncompetitive NMDA receptor antagonists reduces duration of unconsciousness. The mechanism for this effect may involve attenuation of neurotrauma-induced glutamate-mediated excitotoxicity and/or stabilization of glutamate signaling in the injured brain. During the subacute or late post-injury periods, medications that augment cerebral acetylcholinergic function may improve declarative memory. Among responders to this treatment, secondary benefits on attention, processing speed, and executive function impairments as well as neuropsychiatric disturbances may be observed. During these post-injury periods, medications that augment cerebral catecholaminergic function may improve hypoarousal, processing speed, attention, and/or executive function as well as comorbid depression or apathy. When medications are used, a "start-low, go-slow, but go" approach is encouraged, coupled with frequent reassessment of benefits and side effects as well as monitoring for drug-drug interactions. Titration to either beneficial effect or medication intolerance should be completed before discontinuing a treatment or augmenting partial responses with additional medications.
Keywords: Traumatic Brain Injury (TBI)
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Wortzel HS, Arciniegas DB, Anderson CA, Vanderploeg RD, Brenner LA. (2012). A Phase I Study of Low-Pressure Hyperbaric Oxygen Therapy for Blast-Induced Post-Concussion Syndrome and Post-Traumatic Stress Disorder: A Neuropsychiatric Perspective. JOURNAL OF NEUROTRAUMA 29:2421–2424
Abstract not available
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Wortzel HS, Blatchford P, Conner L, Adler LE, Binswanger IA. (2012). Risk of Death for Veterans on Release From Prison. J Am Acad Psychiatry Law 40:3:348-354
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.
Keywords: Incarcerated Veterans
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Zuo CS, Sung YH, Simonson DC, Habecker E, Wang J, Haws C, Villafuerte RA, Henry ME, Dobbins RL, Hodge RJ, Nunez DJ, Renshaw PF. Reduced T2* values in soleus muscle of patients with type 2 diabetes mellitus. PLoS One. 2012;7(11):e49337.
Tissue water transverse relaxation times (T2) are highly sensitive to fluid and lipid accumulations in skeletal muscles whereas the related T2* is sensitive to changes in tissue oxygenation in addition to factors affecting T2. Diabetes mellitus (DM) affects muscles of lower extremities progressively by impairing blood flow at the macrovascular and microvascular levels. This study is to investigate whether T2 and T2* are sensitive enough to detect abnormalities in skeletal muscles of diabetic patients in the resting state. T2 and T2* values in calf muscle of 18 patients with type 2 DM (T2DM), 22 young healthy controls (YHC), and 7 age-matched older healthy controls (OHC) were measured at 3T using multi-TE spin echo and gradient echo sequences. Regional lipid levels of the soleus muscle were also measured using the Dixon method in a subset of the subjects. Correlations between T2, T2*, lipid levels, glycated hemoglobin (HbA1c) and presence of diabetes were evaluated. We found that T2 values were significantly higher in calf muscles of T2DM subjects, as were T2* values in anterior tibialis, and gastrocnemius muscles of T2DM participants. However, soleus T2* values of the T2DM subjects were significantly lower than those of the older, age-matched HC cohort (22.9±0.5 vs 26.7±0.4 ms, p<0.01). The soleus T2* values in the T2DM cohort were inversely correlated with the presence of diabetes (t = -3.46, p<0.001) and with an increase in HbA1c, but not with body mass index or regional lipid levels. Although multiple factors may contribute to changes in T2* values, the lowered T2* value observed in the T2DM soleus muscle is most consistent with a combination of high oxygen consumption and poor regional perfusion. This finding is consistent with results of previous perfusion studies and suggests that the soleus in individuals with T2DM is likely under tissue oxygenation stress.
Keywords: Brain (Neuroanatomy, Neurocognition, Neurotransmitters, etc)
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