Stimulants and Cannabis Use Among a Marginalized Population in British Columbia, Canada: Role of Trauma and Incarceration.

High rates of substance use, especially cannabis and stimulant use, have been associated with homelessness, exposure to trauma, and involvement with the criminal justice system. This study explored differences in substance use (cannabis vs. stimulants) and associations with trauma and incarceration among a homeless population. Data were derived from the BC Health of the Homeless Study (BCHOHS), carried out in three cities in British Columbia, Canada. Measures included sociodemographic information, the Maudsley Addiction Profile (MAP), the Childhood Trauma Questionnaire (CTQ), and the Mini International Neuropsychiatric Interview (MINI) Plus. Stimulant users were more likely to be female (43%), using multiple substances (3.2), and engaging in survival sex (14%). Cannabis users had higher rates of lifetime psychotic disorders (32%). Among the incarcerated, cannabis users had been subjected to greater emotional neglect (p < .05) and one in two cannabis users had a history of lifetime depressive disorders (p < .05). Childhood physical abuse and Caucasian ethnicity were also associated with greater crack cocaine use. One explanation for the results is that a history of childhood abuse may lead to a developmental cascade of depressive symptoms and other psychopathology, increasing the chances of cannabis dependence and the development of psychosis.

Physical and Mental Health Issues among Homeless Youth in British Columbia, Canada: Are they Different from Older Homeless Adults?

OBJECTIVES: Youth homelessness is on the rise in North America, yet this vulnerable population is rarely studied and compared with adults. This paper aimed to study the homeless youth and identify specific vulnerabilities, which rendered them different from the adult homeless population. It also aimed to describe the youth homeless population and their significant co-morbidities. METHODS: DATA WAS DERIVED FROM THE BC HEALTH OF THE HOMELESS STUDY (BCHOHS), CARRIED OUT IN THREE CITIES IN BRITISH COLUMBIA, CANADA: the large urban centre Vancouver (n=250); the mid-sized city and capital of the province Victoria (n=150). Measures included socio-demographic information, the Maudsley Addiction Profile (MAP), the Childhood Trauma Questionnaire (CTQ) and the Mini International Neuropsychiatric Interview (MINI) Plus. RESULTS: Youth constituted 16.5% (n=82) of the homeless population. Compared to the adult homeless, the homeless youth were more often female (55%), were Aboriginal (47.6%), had greater substance abuse of alcohol (70.7%), amphetamines (8.5%) and cannabis (75.6%). A lower prevalence of sexually transmitted diseases (0.2%) and psychotic disorders (13.4%) was also observed. The prevalence of traumatic experiences, other psychiatric disorders and physical illnesses were similar between the adult and homeless youth. CONCLUSION: Homeless youth have high rates of physical and psychiatric comorbidity, similar to the adult homeless, despite being 20 years younger. An urgent need for interventions that go beyond the standardized ones being offered to homeless populations as a whole, and to derive specific strategies that target this vulnerable population is required.

OBJECTIFS: L'itinérance chez les jeunes est en hausse en Amérique du Nord, et pourtant, cette population vulnérable est rarement étudiée et comparée aux adultes. Cet article visait à étudier les jeunes sans-abri et à identifier les vulnérabilités spécifiques qui les rendaient différents de la population adulte des sans-abri. Il visait également à décrire la population des jeunes sans-abri et leurs comorbidités significatives. MÉTHODES: Les données ont été tirées de l'enquête de la C.-B. sur la santé des sans-abri (BCHOHS), menée dans trois villes de la Colombie-Britannique, au Canada : le grand centre urbain de Vancouver (n=250); la ville de taille moyenne et la capitale de la province, Victoria (n=150). Les mesures incluaient les données sociodémographiques, le profil de toxicomanie de Maudsley (MAP), le questionnaire sur les traumatismes subis durant l'enfance (CTQ) et la mini entrevue neuropsychiatrique internationale (MINI) plus. RÉSULTATS: Les jeunes constituaient 16,5% (n=82) de la population sans-abri. Comparé aux adultes sans-abri, les jeunes sans-abri étaient plus souvent de sexe féminin (55%), autochtones (47,6%), abusaient davantage de substances d'alcool (70,7%), d'amphétamines (8,5%) et de cannabis (75,6%). Une prévalence plus faible de maladies transmises sexuellement (0,2%) et de troubles psychotiques (13,4%) a aussi été observée. La prévalence des expériences traumatiques, d'autres troubles psychiatriques et de maladies physiques était semblable chez les sans-abri jeunes et adultes. CONCLUSION: Les jeunes sans-abri ont des taux élevés de comorbidité physique et psychiatrique, semblables à ceux des adultes sans-abri, malgré qu'ils aient 20 ans de moins. Il y a un besoin urgent d'interventions qui vont au-delà de celles qui sont normalisées et offertes à l'ensemble des populations sans-abri, et il faut trouver des stratégies spécifiques qui ciblent cette population vulnérable.

Is impulsivity in remitted bipolar disorder a stable trait? A meta-analytic review.

OBJECTIVE: To review scores on measures of impulsivity in remitted bipolar disorder. DATA SOURCE: We used keywords "impulsivity and bipolar" and "impulsivity and mania" to narrow down our search on Medline, EMBASE and Psychinfo to include those studies that had reported impulsivity scores using validated and reliable assessment measures in remitted bipolar disorder (both I and II). We searched all English language studies from 1990 to October 2012. STUDY SELECTION: Nineteen reports met the inclusion criteria and were reviewed by two abstractors independently. DATA ABSTRACTION: We generated weighted mean differences (WMDs) from pooled data using RevManager 5.0 from Cochrane analysis. RESULTS: The Barratt Impulsivity Scale (BIS) 11 was the instrument most commonly used. Nineteen studies met the inclusion criteria, of which 2 were excluded due to incomplete data. A WMD of 12.8 was observed for BIS 11 total scores, 4.3 on the motor component, 4.1 on the cognitive and 7.6 on the non-planning components of the BIS 11 respectively. CONCLUSION: Impulsivity is significantly higher in remitted bipolar patients than normal controls. Non-planning impulsivity is a key domain affected in bipolar disorder, which may represent a stable trait.

Clinical practice guidelines in psychiatry: more confusion than clarity? A critical review and recommendation of a unified guideline.

The discipline of psychiatry has a plethora of guidelines, designed to serve the needs of the clinician. Yet, even a cursory glance is enough to discern the differences between the various guidelines. This paper reviews the current standard guidelines being followed across the world and proposes a unified guideline on the backbone of current evidence and practice being followed. The algorithm for pharmacological and psychosocial treatment for bipolar disorder, major depressive disorder, and schizophrenia is formulated after cross-comparison across four different guidelines and recent meta-analytical evidence. For every disorder, guidelines have different suggestions. Hence, based on the current status of evidence, algorithms have been combined to form a unified guideline for management. Clinical practice guidelines form the basis of standard clinical practice for all disciplines of medicine, including psychiatry. Yet, they are often not read or followed because of poor quality or because of barriers to implementation due to either lack of agreement or ambiguity. A unified guideline can go a long way in helping clear some of the confusion that has crept in due to the use of different guidelines across the world.

Impulsivity in remitted depression: a meta-analytical review.

AIM: Depressive disorder and suicide have been associated with impulsivity in several studies. This paper aimed to review measures of trait impulsivity in remitted depressive disorder. METHODS: We used keywords "impulsivity and depression"; "impulsivity and depressive disorder" to narrow down our search on Medline, EMBASE and Psychinfo to include those studies that had reported impulsivity scores using validated and reliable assessment measures in remitted depressive disorder. We searched all English language studies from 1990 to December 2012 with 9 reports meeting the inclusion criteria for depression, which were then reviewed by the two reviewers independently. We generated weighted mean differences (WMDs) for depression from the pooled data using RevManager 5.1 from Cochrane analysis. RESULTS: The Barratt Impulsivity Scale (BIS) 11 was the instrument commonly used in depression. 9 studies met inclusion criteria in depression, which yielded a WMD of 10.12 on BIS 11 total scores. CONCLUSION: There is a strong association of impulsivity and depression, which persists even in remission.

Family history of alcohol and drug abuse, childhood trauma, and age of first drug injection.

BACKGROUND: Childhood maltreatment may lead to development of future substance use; however the contributions of a family history of substance use is unclear. OBJECTIVES: To better understand the relationship between childhood abuse, family history of alcohol and drug abuse, and injecting drug use initiation in a cohort of chronic opioid users. METHODS: A cross-sectional survey of long-term and difficult to treat intravenous opiate users of the North American Opiate Medication Initiative (NAOMI) cohort was conducted in two Canadian cities (Vancouver and Montreal). For the analysis, we selected a subsample (n = 87) of the population reported experiencing childhood abuse and completed a 12-month follow up. The sample was 41.4% female and 14.9% First Nations, with a mean age of 38 years. This sample then completed the Childhood Trauma Questionnaire (CTQ) and the Addiction Severity Index (ASI) beside others. RESULTS: Maternal alcohol and drug use was significantly associated with childhood sexual abuse, emotional abuse, and physical neglect. Paternal alcohol and drug use was significantly associated with childhood physical abuse. Increased severity of all types of childhood trauma was related to an earlier age of first injection. CONCLUSIONS/IMPORTANCE: Family history of drug and alcohol use is strongly associated with childhood trauma, which may, in turn, lead to an earlier initiation to the dangerous routes of drug injection.

Homeless and incarcerated: an epidemiological study from Canada.

BACKGROUND: Incarceration and homelessness are closely related yet studied rarely. This article aimed to study the incarcerated homeless and identify specific vulnerabilities, which rendered them different from the nonincarcerated homeless. It also aimed to describe the homeless population and its significant involvement with the criminal justice and enforcement system. METHODS: Data were derived from the British Columbia Health of the Homeless Study (BCHOHS), carried out in three cities in British Columbia, Canada: the large urban center Vancouver (n = 250), Victoria (n = 150) and Prince George (n = 100). Measures included socio-demographic information, the Maudsley Addiction Profile (MAP), the Childhood Trauma Questionnaire (CTQ) and the Mini International Neuropsychiatric Interview (MINI) Plus. RESULTS: Incarcerated homeless were more often male (66.6%), were in foster care (56.4%) and had greater substance use especially of crack cocaine (69.6%) and crystal methamphetamine (78.7%). They also had greater scores on emotional and sexual abuse domains of CTQ, indicating greater abuse. A higher prevalence of depression (57%) and psychotic disorders (55.3%) was also observed. Risk factors identified which had a positive predictor value were male gender (p < .001; odds ratio (OR) = 2.8; 95% confidence interval (CI): 1.7-4.4), a diagnosis of depression (p = .02; 95% CI: 1.1-4.4) and severe emotional neglect (p = .02; 95% CI: 1.1-3.2) in the childhood. CONCLUSION: Homeless individuals may be traumatized at an early age, put into foster care, rendered homeless, initiated into substance use and re-traumatized on repeated occasions in adult life, rendering them vulnerable to incarceration and mental illness.

Gender differences in early trauma and high-risk behaviors among street-entrenched youth in British Columbia.

OBJECTIVE: This work aimed to evaluate gender differences among the street-entrenched youth in British Columbia in terms of their demographics, experiences of childhood maltreatment, mental health issues, and substance use behaviors. MATERIALS AND METHODS: Data were derived from the BC Health of the Homeless Study (BCHOHS), carried out in three cities in British Columbia, Canada. Measures included socio-demographic information, the Maudsley Addiction Profile (MAP), the Childhood Trauma Questionnaire (CTQ), the Mini International Neuropsychiatric Interview (MINI) Plus and the National Survey of Homeless Assistance Providers and Clients (NSHAPC)-Health Chapter. RESULTS: Youth constituted 16.5% (n=82) of the homeless population. Females (55%) outnumbered males and engaged in survival sex more frequently (17.8%; p=0.03). Males had greater substance abuse of alcohol (81.1%) and cannabis (89.2%). Depression (p=0.02) and psychosis (p=0.05) were more common among females, while panic disorder was more common among males (p=0.04). Rates of childhood trauma were similar across genders. CONCLUSION: Our findings reflect trends among youth where illicit drug use may be similar among genders while males may report increased alcohol and cannabis use, possibly as a means to self medicate their panic-related symptoms. In any case, this population of street entrenched-youth frequently experiences several significant problems ranging from childhood abuse to high rates of substance abuse and mental illnesses.

Amisulpride treatment of somatoform disorders: not just chronic fatigue.

Amisulpride has been used to treat psychotic disorders and more recently even chronic fatigue. We describe 2 cases with somatoform disorders and who responded to low-dose amisulpride.

Online interventions for depression and anxiety - a systematic review.

Background: Access to mental health care is limited. Internet-based interventions (IBIs) may help bridge that gap by improving access especially for those who are unable to receive expert care. Aim: This review explores current research on the effectiveness of IBIs for depression and anxiety. Results: For depression, therapist-guided cognitive behavioral therapy (CBT) had larger effect sizes consistently across studies, ranging from 0.6 to 1.9; while stand-alone CBT (without therapist guidance) had a more modest effect size of 0.3-0.7. Even other interventions for depression (non-CBT/non-randomized controlled trial (RCT)) showed modestly high effect sizes (0.2-1.7). For anxiety disorders, studies showed robust effect sizes for therapist-assisted interventions with effect sizes of 0.7-1.7 (efficacy similar to face-to-face CBT) and stand-alone CBT studies also showed large effect sizes (0.6-1.7). Non-CBT/Non-RCT studies (only 3) also showed significant reduction in anxiety scores at the end of the interventions. Conclusion: IBIs for anxiety and depression appear to be effective in reducing symptomatology for both depression and anxiety, which were enhanced by the guidance of a therapist. Further research is needed to identify various predictive factors and the extent to which stand-alone Internet therapies may be effective in the future as well as effects for different patient populations.

Acute Delirium due to Parenteral Tramadol.

Tramadol is a widely used medication by physicians and is held to be a safe analgesic. It has been claimed to be helpful in the elderly and hepatic and renally compromised subjects. We would like to report a case of delirium in a middle-aged female with acute pain abdomen on tramadol while being treated in the surgical unit. The patient developed alteration in the level of consciousness and cognitive deficits following injectable dose of tramadol. She was diagnosed as a case of tramadol-induced delirium. The patient improved spontaneously after stoppage of tramadol injection. The probable mechanism for development of tramadol-induced delirium is discussed along with clinical implications.