May 2011

Vol. 23. No. 2


Choices clinicians must make: When to intervene and how to help

I just returned from Chicago where I attended the annual meeting of the American Academy of Clinical Psychiatrists (AACP) held in collaboration with Current Psychiatry. This was an outstanding meeting. A highlight was the “point/counterpoint” exchange between Drs. Henry Nasrallah and Rajiv Tandon on whether efficacy or tolerability trumps physician choice for antipsychotics. We begin this issue of Annals with a contribution from Simha E. Ravven, MD, and colleagues presenting epidemiologic data from the National Comorbidity Survey Replication on the use of herbals for treating mental illness. These and other forms of alternative care become mainstream and psychiatrists, like other physicians, are not well informed about what our patients are taking. Sydney Chiu, MA, and colleagues test a brief selfreport screener for posttraumatic stress disorder. Their work involved retired firefighters exposed to the terrorist attacks on the World Trade Center in 2001…



12-month herbal medicine use for mental health from the National Comorbidity Survey Replication (NCS-R)

Simha E. Ravven, MD | M. Bridget Zimmerman, PhD | Susan K. Schultz, MD | Robert B. Wallace, MS, MD

BACKGROUND: Herbal medicine is widely used by individuals with mental health problems, although research on their health characteristics and health care utilization patterns—including concomitant treatment with conventional mental health care and psychotropic medication— remains limited.

METHODS: We gathered data from the National Comorbidity Survey Replication (NCS-R), a representative survey of US adults in which diagnoses of mental disorders were based on a fully structured diagnostic interview.

RESULTS: Our analysis found that NCS-R respondents with mental disorders were significantly more likely to have used herbal medicines for mental health problems than respondents who did not meet criteria for a mental disorder. Users of herbal medicines for mental health problems were likely to utilize conventional health care as well, particularly conventional psychiatric medication. Herbal use also was associated with having multiple comorbid medical problems.

CONCLUSIONS: A substantial proportion of US adults use herbal medicine to treat mental health problems. Herbal medicine is frequently used concomitantly with conventional health care, including prescription psychotropic medication. Herbal use also is associated with having multiple chronic medical problems. These factors increase the potential for interactions between herbal medicines and psychiatric and nonpsychiatric medications.


Performance characteristics of the PTSD Checklist in retired firefighters exposed to the World Trade Center disaster

Sydney Chiu, MA | Mayris P. Webber, DrPH | Rachel Zeig-Owens, MPH | Jackson Gustave, MPH | Roy Lee, BS | Kerry J. Kelly, MD | Linda Rizzotto, LCSW, CASAC | Rita McWilliams, PhD | John K. Schorr, PhD | Carol S. North, MD, MPE | David J. Prezant, MD

BACKGROUND: Since the World Trade Center (WTC) attacks on September 11, 2001, the Fire Department, City of New York Monitoring Program has provided physical and mental health screening services to rescue/recovery workers. This study evaluated performance of the self-report PTSD Checklist (PCL) as a screening tool for risk of posttraumatic stress disorder (PTSD) in firefighters who worked at Ground Zero, compared with the interviewer-administered Diagnostic Interview Schedule (DIS).

METHODS: From December 2005 to July 2007, all retired firefighter enrollees completed the PCL and DIS on the same day. Sensitivity, specificity, receiver operating characteristic (ROC) curves, and Youden index (J) were used to assess properties of the PCL and to identify an optimum cutoff score.

RESULTS: Six percent of 1,915 retired male firefighters were diagnosed with PTSD using the DIS to assess DSM-IV criteria. Depending on the PCL cutoff, the prevalence of elevated risk relative to DSM-IV criteria varied from 16% to 22%. Youden index identified an optimal cutoff score of 39, in contrast with the frequently recommended cutoff of 44. At 39, PCL sensitivity was 0.85, specificity was 0.82, and the area under the ROC curve was 0.91 relative to DIS PTSD diagnosis.

CONCLUSIONS: This is the first study to validate the PCL in retired firefighters and determine the optimal cutoff score to maximize opportunities for PTSD diagnosis and treatment.


Strategic vs nonstrategic gambling: Characteristics of pathological gamblers based on gambling preference

Brian L. Odlaug, PhD, MPH | Patrick J. Marsh, MD | Suck Won Kim, MD | Jon E. Grant, JD, MD, MPH

BACKGROUND: Although prior studies have examined various clinical characteristics of pathological gambling (PG), limited data exist regarding the clinical correlates of PG based on preferred forms of gambling.

METHODS: We grouped patients meeting DSM-IV criteria for pathological gambling into 3 categories of preferred forms of gambling: strategic (eg, cards, dice, sports betting, stock market), nonstrategic (eg, slots, video poker, pull tabs), or both. We then compared the groups’ clinical characteristics, gambling severity (using the Yale-Brown Obsessive Compulsive Scale Modified for Pathological Gambling, the Clinical Global Impression– Severity scale, and time and money spent gambling) and psychiatric comorbidity.

RESULTS: The 440 patients included in this sample (54.1% females; mean age 47.69 ± 11.36 years) comprised the following groups: strategic (n = 56; 12.7%), nonstrategic (n = 200; 45.5%), or both (n = 184; 41.8%). Nonstrategic gamblers were significantly more likely to be older and female. Money spent gambling, frequency of gambling, gambling severity, and comorbid disorders did not differ significantly among groups.

CONCLUSIONS: These preliminary results suggest that preferred form of gambling may be associated with certain age groups and sexes but is not associated with any specific clinical differences.


Sleep disturbances in euthymic bipolar patients

Sharon Brill, BS | Praveen Penagaluri,, MD | R. Jeannie Roberts, MD | YongLin Gao, MD | Rif S. El-Mallakh, MD

BACKGROUND: Sleep disturbance has been implicated in both prodromal and syndromal phases of bipolar illness.

METHODS: Charts of bipolar disorder (BD) patients who had been euthymic for at least 2 months were reviewed for mood symptoms, Clinical Global Impression scores, Global Assessment of Functioning scores, and sleep.

RESULTS: Among 116 patients, 10 never achieved a euthymic interval of 2 months’ duration. Among the remaining 106 euthymic patients, 59 (55.6%) had BD I, 23 (21.7%) had BD II, and 24 (22.8%) had BD not otherwise specified (NOS). The mean age was 43.3 ± SD 14.6, and 35% were male. A total of 25 patients (23.6%) had a clinically significant ongoing sleep disturbance (27.1% of those with BD I, 21.7% of those with BD II, and 16.6% of those with BD NOS). Of 16 patients for whom a sleep description was available, 25% had difficulty falling asleep, 81.25% had middle insomnia (2 patients experienced both), and none had early morning awakening. Eleven patients (10.4%) received sleep aids, and 33 (31.1%) received sedating antipsychotics (3 patients received both).

CONCLUSIONS: Sleeping aids and sedating antipsychotics can potentially disguise an underlying sleep disturbance. Thus, it is possible that study patients taking these medications (n = 58; 54.7%) suffer from a sleep disturbance that is being adequately or inadequately treated.