Adverse impact of coercive treatments on psychiatric inpatients' satisfaction with care.

Consumers' satisfaction with inpatient mental health care is recognized as a key quality indicator that prospectively predicts functional and clinical outcomes. Coercive treatment experience is a frequently cited source of dissatisfaction with inpatient care, yet more research is needed to understand the factors that influence consumers' perceptions of coercion and its effects on satisfaction, including potential "downstream" effects of past coercive events on current treatment satisfaction. The current study examined associations between objective and subjective indices of coercive treatments and patients' satisfaction with care in a psychiatric inpatient sample (N = 240). Lower satisfaction ratings were independently associated with three coercive treatment variables: current involuntary admission, perceived coercion during current admission, and self-reported history of being refused a requested medication. Albeit preliminary, these results document associations between patients' satisfaction ratings and their subjective experiences of coercion during both current and prior hospitalizations.

An open-label pilot study of aripiprazole for male and female veterans with chronic post-traumatic stress disorder who respond suboptimally to antidepressants.

Emerging data suggest that second-generation antipsychotics such as aripiprazole may be effective in the treatment of post-traumatic stress disorder (PTSD). However, few clinical trials have used aripiprazole in PTSD, and data are limited on its use in Veterans with PTSD. The objective of this pilot trial was to investigate the safety and efficacy of aripiprazole in Veterans with PTSD. Ten individuals (five men and five women) meeting the Diagnostic and statistical manual of mental disorders, 4th ed., PTSD criteria participated in this 12-week, open-label, flexibly dosed monotherapy trial. The dose range of aripiprazole was 5-30 mg/day, titrated to tolerability and clinical response. The primary outcome measure was the Clinician-Administered PTSD Scale. Additional outcomes included the Short PTSD Rating Interview, the Treatment Outcome PTSD Scale (Top-8), the Davidson Trauma Scale, the Positive and Negative Syndrome Scale, the Beck Depression Inventory-Fast Screen, and Clinical Global Impressions-Improvement. Eight participants completed the study, and aripiprazole was generally well tolerated and associated with a significant improvement in PTSD symptoms, as measured by the Clinician-Administered PTSD Scale (primary outcome measure) and by the Short PTSD Rating Interview, the Treatment Outcome PTSD Scale, and the Davidson Trauma Scale. An improvement was also observed on all three Positive and Negative Syndrome Scale subscales and the Beck Depression Inventory-Fast Screen, and the average Clinical Global Impressions-Improvement ratings indicated that patients were 'much improved'. These promising initial results merit further investigation in a larger, randomized-controlled trial.

Is military sexual trauma associated with trading sex among women veterans seeking outpatient mental health care?

A robust association between sexual trauma and trading sex has been documented in civilian samples but has not been examined in veterans. Women veterans experience high rates of sexual victimization across the lifespan, including during military service (military sexual trauma [MST]). Associations between MST and trading sex were examined in 200 women enrolled in a crosssectional study of HIV risks and seroprevalence among women receiving outpatient mental health care at a Veterans Affairs (VA) medical center. Each woman completed an assessment interview composed of validated measures that queried childhood sexual trauma; substance use; and risk behaviors, including trading sex for money, drugs, shelter, food, or other things. History of MST was derived from mandated VA screening results and chart notes. Overall, 19.7% reported a history of trading sex. Those who reported trading sex had a higher rate of MST than those who did not report trading sex (87.2% vs. 62.9%, respectively). A multivariable logistic regression model examined the relationship between trading sex and MST, controlling a priori for substance abuse and childhood sexual trauma (both associated with trading sex in civilian samples) and education, which was associated with trading sex in our sample. In this adjusted model, MST was associated with trading sex: odds ratio = 3.26, p = .025, 95% confidence interval = [1.16, 9.18]. To our knowledge, this is the 1st report of an association between MST and trading sex. Results extend previously observed associations between sexual trauma and trading sex in civilian cohorts and underscore the pernicious influence of sexual victimization across the lifespan.

A clinical trial comparing interviewer and computer-assisted assessment among clients with severe mental illness.

OBJECTIVE: Demographic, behavioral, and diagnostic information should routinely be collected from clients with severe mental illness, and data gathering should employ the most efficient techniques available. Surveys are increasingly conducted via Web-based computer-assisted interviewing (CAI), but this technique is not well validated for patients with severe mental illness. A randomized clinical trial of 245 clients was carried out to compare face-to face and computer-assisted interviewing (233 clients completed two surveys). METHODS: Self-report data were collected on demographic characteristics, substance abuse, risk behaviors for blood-borne diseases, trauma history, and posttraumatic stress disorder. Each client was assessed twice and randomly assigned to one of the four possible combinations of interviewer and computer (computer and computer, N=53; computer and interviewer, N=56; interviewer and computer, N=59; and interviewer and interviewer, N=65). The two formats were compared on feasibility, client preference, cost, reliability, convergent validity, and criterion validity. RESULTS: This study demonstrated the feasibility of CAI across a variety of inpatient and outpatient settings. All participants who began the CAI process completed the interview and responded to over 95% of the survey items. Participants liked using the computers as well as they liked face-to-face interviews, and they completed the CAI as quickly. CAI produced data as reliable and valid as face-to-face interviews produced and was less expensive, and results were available more quickly. The two formats were similar in criterion validity. CONCLUSIONS: CAI appears to be a viable technology for gathering clinical data from the population with severe mental illness and for transforming such information into a useful, quickly accessible form to aid in clinical decision making.

Assessing risk of violent behavior among veterans with severe mental illness.

Although empirical research has examined factors associated with increased violence risk among individuals with severe mental illness (SMI) and among veterans without SMI, less attention has been devoted to identifying violence risk factors among veterans with SMI. Using multivariable analysis of a large pooled sample of individuals with SMI, this study examines violence risk factors of N = 278 veterans with SMI. In multivariate modeling, violence by veterans with SMI was associated with head injury, posttraumatic stress disorder (PTSD), substance abuse, and homelessness. Results support the view clinicians assessing violence risk among veterans with SMI should consider a combination of characteristics empirically related to violence by non-veterans with SMI (e.g., homelessness) and veterans without SMI (e.g., PTSD).

Interpersonal trauma, war zone exposure, and posttraumatic stress disorder among veterans with schizophrenia.

The present study examined the prevalence of war zone exposure, interpersonal trauma and post-traumatic stress disorder (PTSD) in veterans with primary schizophrenia hospitalized on a VA inpatient psychiatric unit. Data were collected on a sample of male veterans (N=165) with a primary diagnosis of schizophrenia or schizoaffective disorder, who were consecutively admitted to a VAMC inpatient psychiatric unit. The prevalence of interpersonal trauma exposure and comorbid PTSD were assessed. Analyses also explored differences between those patients who had been identified with PTSD to those who screened positive but had not been previously identified as having PTSD. Ninety-six percent of the sample endorsed interpersonal trauma or exposure to a war zone. The prevalence of PTSD was 47% (n=78), although only 14% (n=11) of those who screened positive for PTSD had a diagnosis of PTSD in their medical record. Among those screening positive, having a chart diagnosis of PTSD was associated with more severe PTSD symptoms and combat exposure. Results suggest that PTSD is highly prevalent and under-diagnosed among veterans with schizophrenia. Increased assessment of trauma and PTSD in this population is warranted.

Olanzapine and fluoxetine administration and coadministration increase rat hippocampal pregnenolone, allopregnanolone and peripheral deoxycorticosterone: implications for therapeutic actions.

Olanzapine and fluoxetine elevate the GABAergic neuroactive steroid allopregnanolone to physiologically relevant concentrations in rodent cerebral cortex. It is unknown if these agents also alter pregnenolone or deoxycorticosterone. Since olanzapine and fluoxetine in combination have clinical utility and may demonstrate synergistic effects, we investigated neuroactive steroid alterations following olanzapine, fluoxetine or coadministration. Male rats received IP vehicle, olanzapine, fluoxetine or the combination of both agents in higher-dose (0, 10, 20 or 10/20 mg/kg, respectively) and lower-dose (0, 5, 10 or 5/10 mg/kg, respectively) experiments. Pregnenolone and allopregnanolone levels in hippocampus were determined by gas chromatography/mass spectrometry. Peripheral deoxycorticosterone and other steroid levels were determined by radioimmunoassay. Olanzapine, fluoxetine or the combination increased hippocampal pregnenolone and serum deoxycorticosterone in both higher- and lower-dose experiments, and elevated hippocampal allopregnanolone in higher-dose conditions. No synergistic effects on pregnenolone or allopregnanolone were observed following olanzapine and fluoxetine coadministration compared to either compound alone. Pregnenolone and its sulfate enhance learning and memory in rodent models, and therefore pregnenolone elevations may be relevant to cognitive changes in psychotic and affective disorders. Since pregnenolone decreases have been linked to depression, it is possible that olanzapine- and fluoxetine-induced pregnenolone elevations may contribute to the antidepressant actions of these agents.

The neurosteroid allopregnanolone is reduced in prefrontal cortex in Alzheimer's disease.

BACKGROUND: Few data are currently available investigating neurosteroids (NS) in Alzheimer's disease (AD). The NS allopregnanolone may be decreased in serum and plasma in patients with AD, but it is unclear if allopregnanolone is also reduced in brain. Because a number of NS exhibit neuroprotective effects and impact cognitive performance in rodent models, these molecules may be relevant to the pathophysiology of neurodegenerative disorders. We therefore investigated prefrontal cortex (PFC) NS levels in AD. METHODS: Neurosteroid levels (allopregnanolone, pregnenolone, dehydroepiandrosterone [DHEA]) were determined in postmortem PFC in 14 male subjects with AD and 15 cognitively intact male control subjects by gas chromatography/mass spectrometry preceded by high-performance liquid chromatography purification. RESULTS: Subjects with AD exhibit significant reductions in allopregnanolone compared with cognitively intact control subjects (median levels = 2.50 ng/g vs. 5.59 ng/g, respectively; p = .02). Allopregnanolone levels are inversely correlated with neuropathological disease stage (Braak), r = -.49, p = .007. Median DHEA levels are elevated in subjects with AD (p = .01). CONCLUSIONS: Subjects with AD demonstrate significant reductions in PFC allopregnanolone levels, a finding that may be relevant to neuropathological disease stage severity. Neurosteroids may have utility as candidate biomarkers in AD.

Clozapine markedly elevates pregnenolone in rat hippocampus, cerebral cortex, and serum: candidate mechanism for superior efficacy?

Clozapine demonstrates superior efficacy in patients with schizophrenia, but the precise mechanisms contributing to this clinical advantage are not clear. Clozapine and olanzapine increase the GABAergic neuroactive steroid (NS) allopregnanolone, and it has been hypothesized that NS induction may contribute to the therapeutic actions of these agents. Pregnenolone administration improves learning and memory in rodent models, and decreases in this NS have been associated with depressive symptoms in humans. These pregnenolone characteristics may be relevant to the actions of antipsychotics. We therefore investigated potential pregnenolone alterations in rat hippocampus and cerebral cortex following clozapine, olanzapine, and other second generation agents as a candidate NS mechanism contributing to antipsychotic efficacy. In the first set of experiments, intact, adrenalectomized, and sham-operated male rats received vehicle or clozapine (20 mg/kg) IP. In the second set, male rats received vehicle, olanzapine (5 mg/kg), quetiapine (20 mg/kg), ziprasidone (10 mg/kg) or aripiprazole (5 mg/kg) IP. Pregnenolone levels were determined by gas chromatography/mass spectrometry. Clozapine markedly elevates pregnenolone in rat hippocampus, cerebral cortex, and serum; hippocampal levels were strongly correlated with serum levels (r=0.987). Olanzapine also elevates pregnenolone levels, but to a lesser degree than clozapine. Pregnenolone induction may contribute to the clinical actions of clozapine and olanzapine.

The impact of posttraumatic stress disorder on quality of life and health service utilization among veterans who have schizophrenia.

The present study examined the impact of comorbid posttraumatic stress disorder (PTSD) on health-related quality of life and objective measures of health service utilization in 165 male veterans who have primary schizophrenia. Comorbid PTSD was assessed with the PTSD Checklist. Comorbid PTSD was significantly associated with decreased quality of life and increased medical service utilization, including increased psychiatric hospitalization and increased outpatient physical health visits, even after controlling for other clinical and demographic variables among this sample of patients who had primary schizophrenia. Veterans who have schizophrenia should be screened carefully for exposure to trauma and posttraumatic stress disorder.

Knowledge and risks of human immunodeficiency virus transmission among veterans with severe mental illness.

This study is among the first to examine knowledge about human immunodeficiency virus (HIV) and behavioral risks for HIV transmission among veterans with severe mental illness (SMI), a group at high risk for HIV infection. This study examined associations between accuracy of HIV knowledge, risk behaviors, and clinical and demographic characteristics in a sample of male veteran psychiatric inpatients diagnosed with SMI (N = 353). Results showed high rates of inaccurate HIV knowledge, with > 40% of patients demonstrating some inaccuracies, particularly those related to the progression and symptoms of acquired immunodeficiency syndrome. Inaccurate HIV knowledge was associated with older age, minority status, education level, marital status, no homelessness within the previous 6 months, and no reported history of illicit intranasal drug use. There is a need for more effective HIV prevention interventions for persons with SMI.

Neuroactive steroids are altered in schizophrenia and bipolar disorder: relevance to pathophysiology and therapeutics.

Evidence suggests that neuroactive steroids may be candidate modulators of schizophrenia pathophysiology and therapeutics. We therefore investigated neuroactive steroid levels in post-mortem brain tissue from subjects with schizophrenia, bipolar disorder, nonpsychotic depression, and control subjects to determine if neuroactive steroids are altered in these disorders. Posterior cingulate and parietal cortex tissue from the Stanley Foundation Neuropathology Consortium collection was analyzed for neuroactive steroids by negative ion chemical ionization gas chromatography/mass spectrometry preceded by high-performance liquid chromatography. Subjects with schizophrenia, bipolar disorder, nonpsychotic depression, and control subjects were group matched for age, sex, ethnicity, brain pH, and post-mortem interval (n = 14-15 per group, 59-60 subjects total). Statistical analyses were performed by ANOVA with post-hoc Dunnett tests on log transformed neuroactive steroid levels. Pregnenolone and allopregnanolone were present in human post-mortem brain tissue at considerably higher concentrations than typically observed in serum or plasma. Pregnenolone and dehydroepiandrosterone levels were higher in subjects with schizophrenia and bipolar disorder compared to control subjects in both posterior cingulate and parietal cortex. Allopregnanolone levels tended to be decreased in parietal cortex in subjects with schizophrenia compared to control subjects. Neuroactive steroids are present in human post-mortem brain tissue at physiologically relevant concentrations and altered in subjects with schizophrenia and bipolar disorder. A number of neuroactive steroids act at inhibitory GABA(A) and excitatory NMDA receptors and demonstrate neuroprotective and neurotrophic effects. Neuroactive steroids may therefore be candidate modulators of the pathophysiology of schizophrenia and bipolar disorder, and relevant to the treatment of these disorders.

Lifetime sexual and physical victimization among male veterans with combat-related post-traumatic stress disorder.

Because of the high prevalence of post-traumatic stress disorder (PTSD) among veteran men and the limited research on victimization in this group, we recruited 133 male veterans with combat-related PTSD from a psychiatric inpatient unit and assessed them for lifetime physical and sexual trauma. Results indicated that 96% of the sample had experienced some form of victimization over their lifetimes; 60% reported childhood physical abuse, 41% childhood sexual abuse, 93% adulthood physical assault, and 20% adulthood sexual assault. In the preceding year alone, 46% experienced either physical or sexual assault. These findings support the need for routine inquiry into the histories of noncombat victimization in this cohort. Determining the lifetime history of trauma exposure may have implications for vulnerability to subsequent development of PTSD and the risk of future violence.

Neuroactive steroids and suicidality in posttraumatic stress disorder.

OBJECTIVE: Recent studies suggest that neuroactive steroids may be altered in posttraumatic stress disorder (PTSD). Since high rates of suicidality accompany PTSD, the authors investigated neuroactive steroid levels and correlations to suicide attempts in veterans with this disorder. METHOD: Male veterans with PTSD enrolled in a larger study during inpatient hospitalization (N=130) were assessed for suicidal ideation or suicide attempt in the last 6 months. Serum levels of dehydroepiandrosterone (DHEA), androstenedione, testosterone, and estradiol were determined. The authors investigated associations between neuroactive steroids and suicidality. RESULTS: High rates of suicidality were observed. Close to 70% of these patients had suicidal thoughts, and 25% had attempted suicide in the last 6 months. Patients who had attempted suicide demonstrated significantly higher median DHEA levels than those who had not attempted suicide (15.6 versus 8.3 ng/ml), an association that persisted after adjustment for age. CONCLUSIONS: These findings suggest that higher DHEA levels may be linked to suicidality in veterans with PTSD and may be associated with the risk of self-harm.

Interpersonal trauma and posttraumatic stress disorder in patients with severe mental illness: demographic, clinical, and health correlates.

This study's purpose was to evaluate the prevalence and correlates of posttraumatic stress disorder (PTSD) in persons with severe mental illness. Standardized assessments of interpersonal trauma and PTSD were conducted in 782 patients with severe mental illness receiving services in one of five inpatient and outpatient treatment settings. Analyses examined the prevalence of PTSD and the demographic, clinical, and health correlates of PTSD diagnosis. The overall rate of current PTSD in the sample was 34.8 percent. For demographic characteristics, the prevalence of PTSD was higher in patients who were younger, white, homeless, and unemployed. For clinical and health variables, PTSD was more common in patients with major mood disorders (compared to schizophrenia or schizoaffective disorders), alcohol use disorder, more recent psychiatric hospitalizations, more health problems, more visits to doctors for health problems, and more nonpsychiatric hospitalizations over the past year. The results support prior research documenting the high rates of PTSD in patients with severe mental illness and suggest that PTSD may contribute to substance abuse, psychiatric and medical comorbidity, and psychiatric and health service utilization.

Use of psychiatric and medical health care by veterans with severe mental illness.

Risk behaviors and health care use among 396 initially hospitalized veterans with severe mental illnesses were examined. Health care use was abstracted from Veterans Affairs databases (March 1998 to June 2000) for one year after hospital discharge. Lifetime intravenous drug use was related to increased use of outpatient services, and current alcohol use was related to decreased health care use. Patients with posttraumatic stress disorder had greater use of medical outpatient services than patients with schizophrenia-spectrum disorders, although they had longer hospital stays. These results highlight that veterans with severe mental illness receive more treatment in medical than psychiatric health clinics.

Physiological arousal among women veterans with and without posttraumatic stress disorder.

The purpose of this study was to assess baseline physiological arousal in women veterans with posttraumatic stress disorder (PTSD) in a nonresearch setting. Heart rate, blood pressure, sublingual temperature, and weight were obtained from a retrospective chart review of the medical records of 92 women veterans with and without a diagnosis of PTSD who were seen in an outpatient Veterans Affairs medical center. Women veterans with PTSD had statistically significantly higher mean baseline heart rates compared with women veterans without PTSD. The two groups did not differ statistically in blood pressure measures, sublingual temperature, or body mass index. Based on our analyses, this difference is not likely to be an artifact of age, race, body mass index, smoking status, or medication. The mean resting heart rate of women with PTSD was 83.9 beats per minute; it was 77.5 beats per minute in those without PTSD. This elevation in heart rate among women veterans with PTSD suggests an increase in baseline physiological arousal compared with women veterans without PTSD. Faster resting heart rate has been shown to be associated with a higher risk of developing hypertension and a greater incidence of cardiovascular morbidity and mortality in non-PTSD samples. Further research is needed to determine the physiological effects of PTSD in women.

Racial differences in hepatitis B and hepatitis C and associated risk behaviors in veterans with severe mental illness.

Racial differences in the seroprevalence of and risks for hepatitis B (HBV) and hepatitis C (HCV) were examined in military veterans with severe mental illnesses (SMI). Participants (376; 155 Caucasian, 221 African American) were inpatients at a Veterans Affairs (VA) psychiatric unit in Durham, N.C., from 1998 to 2000. Prevalence rates of HBV and HCV were 21.3% and 18.9%, respectively. African Americans had a higher HBV seroprevalence than did Caucasians: 27.6% versus 12.3%; odds ratio (OR) 2.73; 95% confidence interval (CI)=1.55, 4.79. Although not statistically significant, HCV seroprevalence was also higher for African Americans than it was for Caucasians: 21.3% versus 15.5%; OR=1.47; 95% CI=0.86, 2.53. No racial difference was observed for injection drug use (IDU), the strongest risk indicator for both HBV and HCV. Multivariable analyses indicated that African-American race, IDU, and multiple sex partners in the past six months were related to an increased risk of HBV, whereas IDU and smoking crack cocaine were both independently related to an increased risk of HCV. Thus, veterans with SMI--particularly African-American veterans--have high rates of HBV and HCV infection. African-American veterans have significantly higher rates of HBV than do Caucasian veterans, which persist after controlling for prominent risk behaviors.

Ambulatory monitoring and physical health report in Vietnam veterans with and without chronic posttraumatic stress disorder.

This study investigated the associations among PTSD, ambulatory cardiovascular monitoring, and physical health self-reports in 117 male Vietnam combat veterans (61 with PTSD and 56 without PTSD). PTSD was associated with health symptoms and number of current health conditions beyond the influence of several covariates. PTSD was associated with greater systolic blood pressure variability, and an elevated percentage of heart rate and systolic blood pressure readings above baseline. Higher mean heart rate and an elevated percentage of heart rate above baseline were associated with physical health symptoms. None of the ambulatory monitoring variables mediated the association between PTSD and physical health outcomes. Findings suggest that the interrelationships among ambulatory autonomic responses, PTSD, and physical health deserve more research attention.

The five-site health and risk study of blood-borne infections among persons with severe mental illness.

This article outlines the history and rationale of a multisite study of blood-borne infections among persons with severe mental illness reported in this special section of Psychiatric Services. The general problem of blood-borne diseases in the United States is reviewed, particularly as it affects people with severe mental illness and those with comorbid substance use disorders. The epidemiology and natural history of three of the most important infections are reviewed: the human immunodeficiency virus (HIV), the hepatitis B virus, and the hepatitis C virus. Current knowledge about blood-borne diseases among people with severe mental illness as well as information on current treatment advances for hepatitis C are summarized. A heuristic model, based on the pragmatic, empirical, and conceptual issues that influenced the final study design, is presented. The specific rationale of the five-site collaborative design is discussed, as well as the sampling frames, measures, and procedures used at the participating sites. Alternative strategies for analyzing data deriving from multisite studies that use nonrandomized designs are described and compared. Finally, each of the articles in this special section is briefly outlined, with reference to the overall hypotheses of the studies.