Douglas G. Jacobs

Development of a Brief Screening Instrument: The HANDS

Background: The present study was designed to develop a briefer screening scale of approximately 10 items which maintained the validity of the Zung Self-Rating Depression Scale in a sample similar to that attending National Depression Screening Day (NDSD), as well as a more general audience. Methods: We first administered 70 items from a variety of existing rating scales to 40 subjects who answered an ad for depressed subjects and 55 who answered an ad for non-depressed subjects, all of whose diagnoses were confirmed by the Structured Clinical Interview for DSM-IV (SCID). Based on the correlation between each item and the diagnostic criterion, we reduced the number of items to 17 which we then administered to another 45 subjects who answered an ad similar to that used for NDSD and also underwent a SCID interview. Based on these results, we arrived at the final 10-item Harvard Department of Psychiatry/NDSD scale (HANDS) with the assistance of the item-response theory. The items are scored for frequency of occurrence of each symptom over the past 2 weeks. Total scores range from 0 to 30. Results: The 10-item scale (HANDS) has good internal consistency and validity: a cutpoint score of 9 or greater gave sensitivity of at least 95% in both studies. Although specificity was lower for all scales in the self-selected population, the HANDS performed at least as well as the 20-item Zung Scale, the 21-item Beck Depression Inventory-II and the 15-item Hopkins Symptom Depression Checklist. Conclusion: The 10-item HANDS performs as well as other widely used longer self-report scales and has the advantage of briefer administration time.

Suicide: A Four-pathway Clinical-Biochemical Model

Abstract This chapter, based on a review of recent research as well as data presented in this report, proposes four hypothetical pathways leading to suicide in clinical depression: (1) an acute pathway involving severe anxiety/agitation associated with high brain corticotrophin‐releasing factor (CRF or CRH) levels, (2) trait baseline and reactivity hopelessness, (3) severe anhedonia, and (4) trait impulsiveness associated with low brain serotonin turnover and low total cholesterol as a possible peripheral correlate.

Age Variability in the Association Between Heavy Episodic Drinking and Adolescent Suicide Attempts: Findings From a Large-Scale, School-Based Screening Program

OBJECTIVE Alcohol use is a risk factor for suicidal behavior among adolescents, but it is not clear whether this association is consistent during the adolescent period. This study examined the age-specific associations between heavy episodic drinking (HED) and self-reported suicide attempts in a large and diverse sample of adolescents. METHOD Screening data from 32,217 students, between the ages of 11 and 19 years, in 225 schools were analyzed. Logistic regression analyses estimating the impact of HED on self-reported suicide attempts in the past year were performed. RESULTS Heavy episodic drinking was significantly associated with self-reported suicide attempts (odds ratio 1.78, p <.05) controlling for depressive symptoms. However, there was substantial age variability in this association, with the association between HED and self-reported attempts stronger among younger adolescents. Among youths aged 13 years and younger, those who reported an episode of HED during the past year were roughly 2.6 times more likely to report an attempt than those who did not report HED in the past year, in contrast to 1.2 times among youths aged 18 years and older. CONCLUSIONS Heavy episodic drinking is a clear risk factor for suicidal behavior among younger adolescents, beyond the risk conveyed by depressive symptoms. Further research investigating the bases for increased suicide risk among younger adolescents engaging in HED is warranted. Results provide support to AACAPs practice parameters calling for attention to substance abuse in the assessment of suicide risk and suggest that routine screening for HED by physicians may improve the detection of adolescent suicide risk, particularly among younger adolescents.

Talisman or taboo: the controversy of the suicide-prevention contract.

&NA; The suicide‐prevention contract is a widely used but overvalued clinical and risk‐management technique. The scant information on this topic in the psychiatric and mental health literature is reviewed, along with the literature on collateral subjects including suicide prediction, medicolegal aspects of treating suicidal patients, the therapeutic alliance, and countertransference with suicidal patients. A group of 112 psychiatrists and psychologists was surveyed about their use of suicide‐prevention contracts; the majority of them had never received any formal training on the topic. A combination of factors—the unpredictability of suicide, the many different antecedents to completed suicides, the complex psychological reactions of clinicians (including fear of litigation), the incongruity between clinical and legal usages of the contract concept, and the hazards that come of collapsing a complex treatment process into a few words—limit the applicability of suicide‐prevention contracts. We reason that the use of these contracts is based upon subjective belief rather than on objective data or formal training. We recommend an alternative approach to suicide risk management rooted in the well‐known and well‐defined principles of Informed consent.

Irregular Menses Linked to Vomiting in a Nonclinical Sample : Findings from the National Eating Disorders Screening Program in High Schools

PURPOSE Using data from an eating disorders screening initiative conducted in high schools across the United States, we examined the relationship between vomiting frequency and irregular menses in a nonclinical sample of adolescent females. METHODS A self-report questionnaire was administered to students from U.S. high schools participating in the National Eating Disorders Screening Program in 2000. The questionnaire included items on frequency of vomiting for weight control in the past 3 months, other eating disorder symptoms, frequency of menses, height, and weight. Multivariable regression analyses were conducted using data from 2791 girls to estimate the risk of irregular menses (defined as menses less often than monthly) associated with vomiting frequency, adjusting for other eating disorder symptoms, weight status, age, race/ethnicity, and school clusters. RESULTS Girls who vomited to control their weight one to three times per month were one and a half times more likely (risk ratio [RR] = 1.6; 95% confidence interval [CI] = 1.2-2.2), and girls who vomited once per week or more often were more than three times more likely (RR = 3.2; 95% CI = 2.3-4.4), to experience irregular menses than were girls who did not report vomiting for weight control. Vomiting for weight control remained a strong predictor of irregular menses even when overweight and underweight participants were excluded. CONCLUSIONS Our study adds to the evidence that vomiting may have a direct effect on hormonal function in adolescent girls, and that vomiting for weight control may be a particularly deleterious component of eating disorders.

Application of The APA Practice Guidelines on Suicide to Clinical Practice

This article presents charts from The American Psychiatric Association Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors, part of the Practice Guidelines for the Treatment of Psychiatric Disorders Compendium, and a summary of the assessment information in a format that can be used in routine clinical practice. Four steps in the assessment process are presented: the use of a thorough psychiatric examination to obtain information about the patients current presentation, history, diagnosis, and to recognize suicide risk factors therein; the necessity of asking very specific questions about suicidal ideation, intent, plans, and attempts; the process of making an estimation of the patients level of suicide risk is explained; and the use of modifiable risk and protective factors as the basis for treatment planning is demonstrated. Case reports are used to clarify use of each step in this process.

Evaluation and care of suicidal behavior in emergency settings

The author offers a sequential protocol for the evaluation and care of suicidal behavior in emergency settings. This protocol contains the following components: 1) a review of the limitations of clinical and demographic risk factors; 2) an exploration of frequent negative reactions that arise during the suicidal encounter in clinicians; 3) an objective schema for grading suicidal behavior; 4) an understanding of chronic suicidal behavior; and 5) a flexible treatment approach. Pertinent literature on suicide evaluation and management is reviewed with an emphasis toward the clinical applicability in emergency settings.

The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults

These Practice Guidelines for the Psychiatric Evaluation of Adults mark a transition in the American Psychiatric Association’s Practice Guidelines. Since the publication of the 2011 Institute of Medicine report Clinical Practice Guidelines We Can Trust, there has been an increasing focus on using clearly defined, transparent processes for rating the quality of evidence and the strength of the overall body of evidence in systematic reviews of the scientific literature. These guidelines were developed using a process intended to be consistent with the recommendations of the Institute of Medicine (2011), the Principles for theDevelopment of Specialty Society Clinical Guidelines of the Council of Medical Specialty Societies (2012), and the requirements of the Agency for Healthcare Research andQuality (AHRQ) for inclusion of a guideline in the National Guideline Clearinghouse. Parameters used for the guidelines’ systematic review are included with the full text of the guidelines; the development process is fully described in a document available on the APA website: http:// www.psychiatry.org/File%20Library/Practice/APA-GuidelineDevelopment-Process–updated-2011-.pdf. To supplement the expertise of members of the guideline work group, we used a “snowball” survey methodology to identify experts on psychiatric evaluation and solicit their input on aspects of the psychiatric evaluation that they saw as likely to improve specific patient outcomes (Yager 2014). Results of this expert survey are included with the full text of the practice guideline.

Emergency psychopharmacology: A review and update

The emergency area is a difficult site for the practice of careful psychopharmacology. The detailed history taking and collaborative treatment relationship often found in the consultants office is rarely present. Instead, rapid decisions are made under a variety of pressures, with patients who may be uncooperative and unwilling to be treated. Many emergency patients are concurrently in treatment with a psychotherapist or psychopharmacologist who is available for consultation to the emergency service. When this is possible it is of great potential value, both in arriving more quickly at an appropriate treatment and in preventing a harmful opposition of the patients treatment resources. For patients who are not currently in another treatment, additional helpful information often may be obtained from friends or family members. This is especially useful in treating patients who are acutely psychotic, unable to communicate, or uncooperative with the emergency interview. Although psychopharmacological approaches properly chosen often yield rapid results, medications are only a part of most emergency treatment plans. Medications are ineffective in a variety of crises and cannot replace careful interviewing of patients and others aimed at understanding the exogenous stress, change in interpersonal relationships, intrapsychic conflict, or biological disorder that precipitated an emergency visit. Furthermore, the decision to treat with medications must include a consideration of the adverse effects that may occur. With these limitations in mind, the area of emergency psychopharmacology can provide powerful assistance to emergency clinicians.

Results of National Alcohol Screening Day: College Demographics, Clinical Characteristics, and Comparison with Online Screening.

Objective: The authors evaluated the efficacy of the 2002 college-based National Alcohol Screening Day (NASD) by determining: (1) the demographic and clinical characteristics of the participants that were screened and (2) the degree to which those scoring at hazardous drinking levels received clinical intervention or were referred for further assessment or treatment. Participants: Of 45,368 participants, 23,334 were screened and 14,598 received some form of clinical intervention, defined as advice or referral. Methods: The authors conducted nonparametric and univariate analyses to test for statistical differences in demographics, clinical-characteristics, and interventions-as a function of-screening mode. Results: Nearly 34% of those screened in person had an AUDIT score of 8 or higher, indicating harmful or hazardous drinking. Of these, only 10% had ever undergone alcohol treatment. More than 58% of those screened online scored 8 or higher, and of this group, fewer than 6% had ever undergone alcohol treatment. Conclusions: These data suggest that the in-person event and the online interactive program associated with NASD are serving markedly different populations, particularly with regard to clinical indicators.