Eric D. Caine

Chronic parkinsonism secondary to intravenous injection of meperidine analogues

Abuse of 4-propyloxy-4-phenyl-N-methylpiperidine, a meperidine congener, produced parkinsonism in a 23-year-old man. Unlike other drug-induced motor disturbances, the syndrome persisted for 18 months and responded to drugs that stimulate dopamine receptors. Biogenic amines and metabolites in the cerebrospinal fluid and microscopic evaluation of the brain at necropsy were consistent with damage to aminergic neurons in the substantia nigra.

Risk factors for suicide in later life.

Suicide rates are higher in later life than in any other age group. The design of effective suicide prevention strategies hinges on the identification of specific, quantifiable risk factors. Methodological challenges include the lack of systematically applied terminology in suicide and risk factor research, the low base rate of suicide, and its complex, multidetermined nature. Although variables in mental, physical, and social domains have been correlated with completed suicide in older adults, controlled studies are necessary to test hypothesized risk factors. Prospective cohort and retrospective case control studies indicate that affective disorder is a powerful independent risk factor for suicide in elders. Other mental illnesses play less of a role. Physical illness and functional impairment increase risk, but their influence appears to be mediated by depression. Social ties and their disruption are significantly and independently associated with risk for suicide in later life, relationships between which may be moderated by a rigid, anxious, and obsessional personality style. Affective illness is a highly potent risk factor for suicide in later life with clear implications for the design of prevention strategies. Additional research is needed to define more precisely the interactions between emotional, physical, and social factors that determine risk for suicide in the older adult.

Risk of suicide and related adverse outcomes after exposure to a suicide prevention programme in the US Air Force: cohort study

Abstract Objective To evaluate the impact of the US Air Force suicide prevention programme on risk of suicide and other outcomes that share underlying risk factors. Design Cohort study with quasi-experimental design and analysis of cohorts before (1990-6) and after (1997-2002) the intervention. Participants 5 260 292 US Air Force personnel (around 84% were men). Intervention A multilayered intervention targeted at reducing risk factors and enhancing factors considered protective. The intervention consisted of removing the stigma of seeking help for a mental health or psychosocial problem, enhancing understanding of mental health, and changing policies and social norms. Main outcome measures Relative risk reductions (the prevented fraction) for suicide and other outcomes hypothesised to be sensitive to broadly based community prevention efforts, (family violence, accidental death, homicide). Additional outcomes not exclusively associated with suicide were included because of the comprehensiveness of the programme. Results Implementation of the programme was associated with a sustained decline in the rate of suicide and other adverse outcomes. A 33% relative risk reduction was observed for suicide after the intervention; reductions for other outcomes ranged from 18-54%. Conclusion A systemic intervention aimed at changing social norms about seeking help and incorporating training in suicide prevention has a considerable impact on promotion of mental health. The impact on adverse outcomes in addition to suicide strengthens the conclusion that the programme was responsible for these reductions in risk.

Validation of a Measure of Physical Illness Burden at Autopsy: The Cumulative Illness Rating Scale

Objective: To further validate an objective measure of physical illness burden, the Cumulative Illness Rating Scale (CIRS).

The importance of subsyndromal depression in older primary care patients: prevalence and associated functional disability.

OBJECTIVE: Existing diagnostic categories for depression may not encompass the majority of older people suffering clinically significant depressive symptoms. We have described the prevalence of subsyndromal depressive symptoms and tested the hypothesis that patients with subsyndromal depression have greater functional disability and general medical burden than nondepressed subjects but less than patients with diagnosable depressions.

Current State of Research on Decision-Making Competence of Cognitively Impaired Elderly Persons

As the number of cognitively impaired elderly persons increases, the need for evidence-based assessments of their capacity to consent to medical treatment and research participation will grow. The authors conducted an electronic and manual literature search for all English-language articles examining the decision-making capacity of elderly persons with dementia or cognitive impairment, reviewing articles in relation to key areas of methodological, clinical, and policy importance. The 32 relevant studies identified were highly heterogeneous, even in their definitions and measurements of decisional capacity. Although incapacity is common, many persons with dementia are capable of making their own medical and research decisions. In Alzheimer disease, memory and executive-function deficits predict decisional impairment. Still, at least in early stages of dementia, interventions may improve decisional abilities. Short and simple cognitive screening may be useful by identifying persons in need of more intensive evaluations. The use of expert judgment-based methods may mitigate the problem of a lack of a criterion standard for competence. Research into the decision-making competence of cognitively impaired elderly persons is a growing field. It is beginning to yield findings with practical implications for preserving the autonomy and welfare of this group of vulnerable elderly patients.

Completed suicide among older patients in primary care practices: a controlled study.

OBJECTIVE: To determine whether physical and psychiatric illness, functional status, and treatment history distinguish older primary care patients who committed suicide from those who did not.

Methadone treatment of randomly selected criminal addicts.

Abstract The potential motivation of criminal addicts for methadone treatment was tested in the New York City Correctional Institute for Men. Of 165 inmates seen, all with records of five or more jail sentences, 116 (70 per cent) applied for treatment after a single interview. None of them had previously made application to the methadone program. Of 18 randomly selected from all applicants with release dates between January 1 and April 30, 1968, 12 were started on methadone before they left jail and then referred to the program for aftercare. None of them became readdicted to heroin, and nine of 12 had no further convictions during the 50 weeks of follow-up study. All of an untreated control group became readdicted after release from jail, and 15 of 16 were convicted of new crimes during the same follow-up period.

Age Differences in Behaviors Leading to Completed Suicide

The authors described retrospectively the premorbid self destructive behaviors of suicide victims to determine whether these behaviors differ with age. One hundred forty one suicide victims, age 21-92 years, were studied by psychological autopsy. Older age was significantly associated with more determined and planful self-destructive acts, less violent methods, and fewer warnings of suicidal intent. Age differences in the behaviors leading to suicide indicate that intervention in the midst of a suicidal crisis may be less effective in elderly persons than in younger people. Primary prevention should be the focus of efforts to decrease suicide rates in late life.

Means restriction for suicide prevention

Limitation of access to lethal methods used for suicide--so-called means restriction--is an important population strategy for suicide prevention. Many empirical studies have shown that such means restriction is effective. Although some individuals might seek other methods, many do not; when they do, the means chosen are less lethal and are associated with fewer deaths than when more dangerous ones are available. We examine how the spread of information about suicide methods through formal and informal media potentially affects the choices that people make when attempting to kill themselves. We also discuss the challenges associated with implementation of means restriction and whether numbers of deaths by suicide are reduced.