Integrated treatment of comorbid depression and substance use disorders.

OBJECTIVE: The goals of this 6-month prospective study were to evaluate the effect of a current diagnosis of depression on the course and outcome of addiction treatment and to determine whether patients with depression received or required additional treatment compared with those without depression. METHOD: On entering addiction treatment, 75 men and 45 women with substance use disorders were assessed by clinical and semistructured interviews, Global Assessment Scale, Hamilton Rating Scale for Depression, Beck Depression Inventory, and revised 90-item Symptom Checklist. RESULTS: Forty-three patients (35.8%) met DSM-IV criteria for a current depressive disorder at intake into addiction treatment. The depressed patients had significantly (p < .0001) higher levels of psychopathology at intake. However, contrary to previous studies, they fared as well as the nondepressed patients in terms of all addiction outcome measures and all indicators of psychiatric status at 6 months. During the 6-month follow-up period, the depressed patients received more treatment than the nondepressed patients. Specifically, they had more psychiatric appointments, and they were more likely to require inpatient detoxification and to be prescribed new antidepressant medication regimens. CONCLUSION: Depression comorbidity may not have had a negative impact on the course and outcome of addiction treatment because the dual disorder was identified at the initial assessment, and integrated psychiatric care was available. It may be that additional treatment compensated for greater psychopathology among dual-disorder patients.

Neuropsychological functioning in substance-dependent patients.

The present study examined neurocognitive functioning in groups of individuals addicted to various psychoactive substances. One hundred ten patients admitted to treatment for substance misuse were assessed using a semistructured clinical interview, the Beck Depression Inventory, the Symptom CheckList-90, the Trail Making A and B tests, and the Shipley Institute of Living Scale. Results revealed that at intake, alcohol- and benzodiazepine-addicted clients exhibited higher levels of cognitive impairment and psychological distress than patients dependent on other drugs. Regression analysis showed that the Shipley vocabulary raw score was a significant predictor of length of stay in treatment.

"Pauci-Immune" proliferative and necrotizing glomerulonephritis with thrombotic microangiopathy in patients with systemic lupus erythematosus and lupus-like syndrome.

In the glomerulonephritides of systemic lupus erythematosus (SLE), the number of subendothelial deposits, when present, generally corresponds to the degree of light microscopic glomerular hypercellularity; only very rarely are no or few such deposits present in cases of focal (WHO class III) or diffuse (WHO class IV) proliferative lupus nephritis. We have recently encountered five cases of active diffuse proliferative glomerlonephritis with no subendothelial and few or no mesangial deposits and thrombotic microangiopathy (TMA) in four patients with SLE and one patient with lupus-like syndrome. Three of the five patients were tested for circulating lupus anticoagulants or anticardiolipin antibodies, and two were positive. All five patients tested negatively for antineutrophil cytoplasmic antibodies (ANCA). Three patients responded to steroid and cyclophosphamide treatment, although one of them died of acute bacterial bronchopneumonia. One patient was lost to follow-up. We conclude that "pauci-immune" proliferative lupus nephritis is rare and should be treated as proliferative lupus nephritis with a proportionate number of subendothelial deposits. The negative ANCA suggests that these cases do not represent incidental ANCA-associated pauci-immune necrotizing and crescentic glomerulonephritis in patients with SLE. Of particular interest is that, in patients with SLE, if associated with TMA, an active proliferative necrotizing glomerulonephritis may be present even in the absence of significant glomerular immune complex deposition.

The treatment of sedative-hypnotic dependence: evaluating clinical predictors of outcome.

BACKGROUND: The objectives of this 6-month prospective study were to evaluate the efficacy of detoxification treatment for sedative-hypnotic dependence, examine the demographic and clinical predictors of outcome, and determine whether anxiety or other psychiatric comorbidity has a negative impact on outcome. METHOD: Eighty-two patients with alcohol or benzodiazepine dependence (DSM-IV diagnostic criteria) were consecutively recruited upon entering treatment and were assessed by clinical and semistructured interviews, the Global Assessment Scale, the Hamilton Rating Scale for Depression, the Beck Depression Inventory, the revised 90-item Symptom Checklist, and urine drug screening. RESULTS: Both alcohol- and benzodiazepine-dependent patients succeeded in reducing their reported use of sedative-hypnotic substances during the follow-up period. However, at 3 months, benzodiazepine-dependent patients fared less well than alcohol-dependent patients in terms of several outcome measures: they reported a lower rate of achieving abstinence, shorter periods of continuous abstinence, and more frequent drug use. At 6 months, the differences in outcome among the drug groups were not maintained. Variables such as sex, drug group, and indicators of psychiatric status had little impact on outcome measures. Benzodiazepine-dependent patients reported significant decreases in their level of anxiety over the follow-up period despite substantial reductions in benzodiazepine use. CONCLUSION: Clinicians may be encouraged regarding the detoxification of patients who have used benzodiazepines at high doses or for long periods of time, or who have comorbid anxiety or other psychiatric disorders.

An abstinence-oriented program for substance use disorders: poorer outcome associated with opiate dependence.

OBJECTIVES: To evaluate the characteristics of patients with various substance-related disorders, and to examine rates of retention in treatment. METHODS: We assessed the demographic characteristics, substance abuse, and psychological distress of 239 men and women at admission. Six-month performance was evaluated, using as criteria length of stay in treatment, abstinence, attendance in therapy sessions, and completion status at discharge. RESULTS: Moderate to severe psychological distress was observed among these individuals. Higher levels of depression were found among women and in individuals with alcohol and sedative use disorders. The primary drug of abuse, frequency of use, and reason for entering treatment were the most significant predictors of retention. CONCLUSIONS: Opiate-addicted clients had the worst prognosis and treatment profiles. Further research is needed to identify factors that would optimize treatment for opiate dependence.

Plasma cell-rich acute renal allograft rejection.

BACKGROUND: Acute renal allograft rejection is usually seen within the first 3 months posttransplant, and is characterized by an intense infiltrate of T cells. Some acute rejections, however, contain many plasma cells and/or appear late posttransplant. METHODS: We have investigated 27 cases of intensely plasma cell-rich acute rejections (PCAR) from 1987 to 1997 and have compared them to 21 control cases (CAR) of typical acute rejection. Each group was divided into early (<6 months) and late (>6 months) subgroups. PCAR and CAR cases were matched for histological features of chronic allograft nephropathy. In all four groups, most cases had Banff '97 type IB and IIA acute rejection. RESULTS: A significantly greater number of PCAR cases experienced graft failure due to chronic allograft nephropathy or complications of acute rejection (P<0.05). There was no significant difference between PCAR and CAR in HLA matching, occurrence of posttransplant acute tubular necrosis, presence versus absence of previous allografts, number of previous or subsequent acute rejection episodes, Banff '97 sum scores for acute rejection, cyclosporine A or FK506 levels, or percent change from baseline creatinine at time of biopsy. Plasma cells in PCAR cases showed IgG predominance whereas those in CAR had comparable staining for IgG and IgA. Kappa and lambda light chain immunostaining of all PCAR cases revealed polyclonality. Three of 18 PCAR cases studied for the presence of Epstein-Barr virus RNA showed scattered positivity in 2-7% of lymphoid cells, although the remainder was negative. None of the PCAR cases developed post-transpland lymphoproliferative disorder. CONCLUSIONS: We conclude that PCAR can occur from 1 month to many years posttransplant, is associated with poor graft survival, and is not a manifestation of concomitant chronic allograft nephropathy or viral infection, including posttransplant lymphoproliferative disorder.

Pulmonary immunocytoma with massive crystal storing histiocytosis: a case report with review of literature.

An unusual immunocytoma (lymphoplasmacytoid lymphoma) composed predominantly of sheets of globoid and spindle-shaped crystal-storing histiocytes was detected incidentally in the right lung of a 72-year-old woman. Scattered lymphoplasmacytic aggregates within the tumor had monoclonality with anti-kappa immunoglobulin (Ig) M antibodies. The crystals were outlined positively by the same antibodies. They stained an intense blue with phosphotungstic acid-hematoxylin (PTAH) and were found during electron microscopy to be membrane bound and also within type I pneumocytes and the extracellular space. Excessive production of kappa IgM by neoplastic low-grade lymphoplasmacytoid cells of B-cell origin in an altered intra- or extracellular milieu may lead to crystallization and phagocytosis by reactive histiocytes. Review of the literature revealed seven more cases: four in the head and neck, and one each in the skin, the lymph node, and the lung. IgM was the most frequently crystallizing immunoglobulin (four of seven) and all had kappa light chains. The lesion needs to be differentiated from neoplastic and nonneoplastic histiocytic and lymphoplasmacytic disorders. The difference with bronchial mucosa-associated lymphoid tissue lymphoma and marginal zone lymphoma is, perhaps, semantic.

Alcohol consumption and major depression in the Canadian population.

OBJECTIVE: Various clinical studies have documented associations between alcohol consumption and depressive disorders. In some circumstances, alcohol ingestion may cause or worsen depression, whereas in other circumstances the direction of causal effect may be reversed. The objective of this study was to evaluate associations between alcohol consumption and major depression in the Canadian population. METHOD: Data from the Canadian National Population Health Survey (NPHS) were analyzed. This survey, conducted by Statistics Canada in 1994, used a probability sample of 17,626 subjects. The NPHS included measures of alcohol ingestion and a diagnostic screen for major depression (Composite International Diagnostic Interview [CIDI] Short Form). RESULTS: Subjects reporting any drinking in the year preceding the interview were more likely to have experienced an episode of major depression during that time than subjects reporting no drinking. Subjects reporting maximal ingestions of 5 or more drinks (and especially 10 or more drinks) on at least 1 occasion during the preceding year were also at greater risk of major depression than nondrinking subjects or subjects reporting smaller maximal ingestions. Neither the average amount consumed daily nor the frequency of drinking was associated with major depression. CONCLUSIONS: In the general population, there is no simple relationship between the quantity or frequency of alcohol consumption and the prevalence of major depression. Any drinking and maximal consumption on 1 occasion, however, are related to the prevalence of major depression. Further research is needed to delineate causal mechanisms so that clinical and public-health interventions can be formulated.

The impact of depression on the outcome of addictions treatment.

The objectives of this study were to examine the prevalence and presentation of depression among patients with substance use disorders, and to explore the relationship between depression and the outcome of addictions treatment. Seventy-five patients were consecutively recruited upon entering addictions treatment, and were assessed by clinical and semi-structured interviews, Hamilton Rating Scale for Depression, Global Assessment Scale, and Beck Depression Inventory. At intake, 22.4% of patients had primary depressive disorders, 8.4% had substance-induced depressions, and 5.6% had mixed features of primary and substance-induced depressions. Female and alcoholic patients were more likely to suffer from both primary and substance-induced depressions. At 3 months, 93.3% of patients were reinterviewed. Depressed patients had longer duration of abstinence and greater decreases in symptomatology. Patients with substance-induced depression achieved almost complete discontinuation of primary substance use. Depression had a significant impact on addictions treatment outcome, but many important predictors of outcome have not yet been identified.

Teaching on gender-related issues; a survey of psychiatry faculty and residents.

A survey was distributed to 299 members of the McGill Department of Psychiatry regarding the teaching of gender-related issues. The response rate was 62.5%. The majority of respondents indicated that they were moderately or very knowledgeable about, and moderately or very interested in gender issues. Current teaching was rated as less than adequate, while future teaching was rated as very important. Women rated personal interest and importance of future teaching higher than men, but rated adequacy of current teaching lower. Residents rated personal interest higher than certified psychiatrists, but rated self-assessed knowledge lower, and tended to rate adequacy of current teaching lower.

Primitive neuroectodermal tumor of the myocardium: a case report, review of the literature, immunohistochemical, and ultrastructural study.

We report the case of a primitive neuroectodermal tumor (PNET) arising in the heart of a 63-year-old man. The neuroectodermal nature of this tumor was confirmed by the immunohistochemical positivity for O13 (CD99) (the P30/32MIC2 gene product) neuron specific enolase (monoclonal and polyclonal), synaptophysin and vimentin. Other markers, such as actin, desmin, myoglobin, chromogranin, keratin, and leukocyte common antigen were negative. The diagnosis was made on an endomyocardial biopsy and was confirmed in sections from the myocardial tumor found within the heart excised during cardiac transplant. Primitive neuroectodermal tumors have been reported in a variety of sites, most commonly in the extremities. No case has ever been reported within the myocardium, although one has been reported in the pericardium. In addition to morphological similarities, PNET and extraskeletal Ewing's sarcoma have been shown to possess the same chromosomal translocation, t11;22, and the same cell surface antigen, P 30/32. Separation of this case from extraskeletal Ewing's sarcoma was possible because of the absence of PAS positivity, as well as the immunohistochemical positivity for at least two neural markers, as extraskeletal Ewing's sarcoma is only positive for neuron specific enolase.

An overview of sexual harassment.

OBJECTIVE: A few widely publicized cases have made sexual harassment a salient subject in the 1990s. This article reviews the topic in a comprehensive manner, with particular attention to demographic information, psychosocial consequences, appropriate therapeutic interventions, and related psychological issues. METHOD: Computerized literature searches were used to identify research and review papers from psychiatry and psychology journals. Nonscientific works that provide additional information are also cited. RESULTS: The literature suggests that sexual harassment is a widespread phenomenon, affecting 42% of women and 15% of men in occupational settings, 73% of women and 22% of men during medical training, and lower percentages in other educational settings. Despite the pervasive nature of this problem, only 1%-7% of victims file formal complaints. Sexual harassment produces an array of psychological and physical symptoms in over 90% of victims, and 12% seek help from mental health care professionals. Self-doubt is a central issue regardless of gender, but in instances where the perpetrator is male and the victim is female, there are ramifications unique to the trauma of gender-based abuse. It is critical that therapists avoid contributing to the process of "second injury" and not imply that patients have brought their troubles on themselves. Key therapeutic tasks include empathy, validation, and empowerment. CONCLUSIONS: Few experimental studies have focused on the victims of sexual harassment, and none have focused on the perpetrators. Psychiatry can play an invaluable role in the assessment and treatment of victims, the fostering of education and research in this area, and the understanding of underlying psychological and gender issues.