Jacques Tremblay

The sequelae of political violence: assessing trauma, suffering and dislocation in the Peruvian highlands.

In this article, we begin with a qualitative mapping of the multiple ways indigenous peoples in the Peruvian highlands construct their emotions, symptoms and specific disorders when confronted with an adverse environment of sustained political violence, multiple stressors and massive exposure to traumatic experiences. Second, we address the issue of magnitude (point prevalence) and distribution of mental health problems such as depression and anxiety, and sequelae of exposure to violence-related stressors as reported in the selected populations, by reviewing the quantitative results of a cross-sectional survey. Third, we examine the pathways and linkages between the social context (drawn from ethnography and secondary sources) and the collective experience, such as massive exodus, forced displacement, resilience and accommodation strategies for coping and survival. When assessing the overall mental health impact of exposure to protracted forms of extreme violence in civilian populations, we argue for the need to move beyond the limited notion of post-traumatic stress disorder, which is a useful but restrictive medical category failing to encompass the myriad of signals of distress, suffering and affliction, as well as other culture bound trauma-related disorders and long-term sequelae of traumatic experiences. Lastly, following the concluding remarks, we discuss some implications the results of the study may have at various levels, not only for the victims and survivors of massive exposure to traumatic events, but also their families and communities, as well as for interventions carried out by humanitarian and emergency relief organizations, and specialised agencies engaged in the promotion of social justice, prevention of human rights abuses, and mental health rehabilitation programs at both national and international levels.

Matching substance abuse aftercare treatments to client characteristics.

This study investigated matching client attributes to different aftercare treatments. A naturalistic sample of adults entering substance abuse treatment was randomized into either Structured Relapse Prevention (RP, n=61) or a 12-Step Facilitation (TSF, n=72) aftercare program. Four patient attributes were matched to treatment: age, gender, substance abuse profile, and psychological status. Substance use outcomes were assessed 3 and 6 months posttreatment. At 6 months, four significant matches were uncovered. Females and individuals with a multiple substance abuse profile reported better alcohol outcomes with TSF aftercare than their cohorts exposed to RP aftercare. Individuals with high psychological distress at treatment entry were able to maintain longer periods of posttreatment abstinence with TSF aftercare compared to their cohorts exposed to RP. Inversely, RP was found to maintain abstinence significantly longer for individuals reporting low distress compared to those with high distress. Finally, better outcomes were achieved when random assignment to aftercare was consistent with participant preference. Overall, an Alcoholics Anonymous approach to aftercare appears to provide the most favorable substance use outcomes for most groups of substance abusers. RP may be most suitable for clients whose psychological distress is low, especially where maintenance of abstinence is targeted. Where choice in aftercare program is possible, matching client preference with type of aftercare program can improve outcome.

Brief Motivational Interviewing for DWI Recidivists Who Abuse Alcohol and Are Not Participating in DWI Intervention: A Randomized Controlled Trial

BACKGROUND Driving while impaired (DWI) recidivists with unresolved alcohol use problems pose an ongoing risk for traffic safety. Following conviction, many do not participate in mandated alcohol evaluation and intervention programs, or continue to drink problematically after being relicensed. This study investigated if, in DWI recidivists with alcohol problems and not currently involved in DWI intervention, Brief Motivational Interviewing (BMI) produced greater reductions in risky drinking at 6- and 12-month follow-up compared to an information-advice control condition. Additional analyses explored whether BMI was associated with greater readiness to change, subsequent substance abuse treatment service utilization, and satisfaction compared to the control condition. METHODS Male and female recidivists with drinking problems and not currently engaged in DWI intervention were recruited, evaluated, and then randomly assigned to receive 1 of 2 manualized interventions: 30-minute BMI session or information-advice. Participants, interviewers, researchers, and statisticians were blind to assignment. Outcomes were changed in: percent of risky drinking days (i.e., > or =3 standard drinks/d for males; > or =2 for females) in the previous 6 months derived from the Timeline Followback, biomarkers of alcohol abuse (GGT, AST, ALT, MCV) by blood assay, and alcohol abuse-related behaviors using the MMPI-Mac scale. Data from the Readiness to Change Questionnaire, a substance abuse service utilization questionnaire, and the Client Satisfaction Scale were also collected. RESULTS Analyses revealed significant declines in risky drinking with both interventions. BMI (n = 92) resulted in a 25% reduction in risky drinking days at 12-month follow-up, which compared to the control intervention (n = 92) represented a significant decline from 6-month levels. Exposure to BMI also produced significantly greater improvement at 6-month follow-up in a biomarker of alcohol abuse and a behavioral measure related to recidivism risk. Exploration of readiness to change, substance abuse service utilization, and satisfaction with intervention indicated a perception of BMI being more useful in coping with problems. CONCLUSIONS Brief MI approaches warrant further implementation and effectiveness research as an opportunistic DWI intervention strategy to reduce risks associated with alcohol use outside of clinical and DWI relicensing settings.

Prevalence of psychological distress and mental disorders, and use of mental health services in the epidemiological catchment area of Montreal South-West

BackgroundThis report presents the initial results of the first Epidemiological Catchment Area Study in mental health in Canada. Five neighbourhoods in the South-West sector of Montreal, with a population of 258,000, were under study. The objectives of the research program were: 1) to assess the prevalence and incidence of psychological distress, mental disorders, substance abuse, parasuicide, risky behaviour and quality of life; 2) to examine the links and interactions between individual determinants, neighbourhood ecology and mental health in each neighbourhood; 3) to identify the conditions facilitating the integration of individuals with mental health problems; 4) to analyse the impact of the social, economic and physical aspects of the neighbourhoods using a geographic information system. 5) to verify the adequacy of mental health services.MethodA longitudinal study in the form of a community survey was used, complemented by focused qualitative sub-studies. The longitudinal study included a randomly selected sample of 2,433 individuals between the ages of 15 and 65 in the first wave of data collection, and three other waves are projected. An overview of the methods is presented.ResultsThe prevalence of psychological distress, mental disorders and use of mental health services and their correlates are described for the first wave of data collection.ConclusionSeveral vulnerable groups and risk factors related to socio-demographic variables have been identified such as: gender, age, marital status, income, immigration and language. These results can be used to improve treatment services, prevention of mental disorders, and mental health promotion.

Trauma reactivation under the influence of propranolol: an examination of clinical predictors

Background In two recent studies conducted by our group, a treatment combining propranolol with a brief reactivation session subsequently reduced posttraumatic stress disorder (PTSD) symptom severity and diagnosis, as well as reducing psychophysiological responses during trauma-related script-driven imagery. One likely explanation for those results is that memory reconsolidation was blocked by propranolol. Objective We explored the influence of various predictors on treatment outcome (i.e., PTSD severity), and whether the treated individuals improved in other important domains of functioning associated with PTSD. Method Thirty-three patients with longstanding PTSD participated in a 6-week open-label trial consisting of actively recalling ones trauma under the influence of propranolol, once a week. Results Treated patients reported a better quality of life, less comorbid depressive symptoms, less negative emotions in their daily life and during trauma recollections. Women were also found to improve more than men. Type of trauma (childhood vs. adulthood), time elapsed since trauma, borderline personality traits, depressive symptoms severity, Axis I comorbidity, and age did not influence treatment outcome. Conclusion These results must await publication of a randomized-controlled trial to further delineate effectiveness with this novel treatment approach. For the abstract or full text in other languages, please see Supplementary files under Reading Toolsonline

Alcohol and cocaine abusers 6 months after traditional treatment: do they fare as well as problem drinkers?

Problem drinkers (N = 49) and individuals presenting with both alcohol and cocaine problems (N = 51) admitted to a traditional 28-day alcoholism treatment milieu were compared on their psychosocial, psychological, neuropsychological functioning and substance abuse at admission as well as at six months posttreatment follow-up. On admission, alcohol and cocaine patients were younger, more likely to live alone or with their family of origin, to report having started using alcohol at an earlier age, to have fewer alcohol-related problems and to have fewer years of but more diversity in their substance abuse than the alcohol-only patients. Otherwise both groups were more similar than different on psychosocial, psychological and neuropsychological dimensions. At six-months posttreatment, both groups showed similar improvement on most dimensions of functioning measured. However, a significantly greater proportion of the alcohol and cocaine abusers admitted to having relapsed in the previous six months, reported significantly fewer average days of abstinence than the alcohol group since terminating treatment, and were more likely to present urine specimens indicative of recent substance abuse at the six-month follow-up interview. Thus, traditional approaches to alcoholism treatment may be less effective in establishing abstinence for individuals with both alcohol and cocaine problems. Adaptations to treatment to reduce the risk for relapse faced by alcohol and cocaine abusers in such milieu are discussed.

Trauma reactivation plus propranolol is associated with durably low physiological responding during subsequent script-driven traumatic imagery.

Objective: In a previous, double-blind, placebo-controlled study, patients with posttraumatic stress disorder (PTSD) showed lower physiological response during script-driven traumatic imagery 1 week after receiving a single dose of propranolol given after the retrieval of a traumatic memory. We hypothesized that this effect would extend beyond 1 week using a modified treatment approach. Method: Twenty-eight participants with PTSD read an account of their traumatic event once weekly for 6 consecutive weeks under the influence of open-label propranolol. One week and 4-months later, skin conductance, heart rate, and left corrugator electromyogram responses were measured while participants engaged in script-driven mental imagery of their traumatic event. Results from the 22 study participants were compared with results from treated and untreated participants in a previously published trial. Results: Most participants in our study were classified as non-PTSD cases at posttreatment and follow-up according to a psychophysiological discriminant function analysis. Posttreatment skin conductance and heart rate responses of the current (propranolol-treated) participants were lower than those of placebo participants from the previous study. No difference was observed between physiological responding measured posttreatment and at follow-up. Conclusions: Low physiological responding during script-driven traumatic imagery after treatment extends up to 4 months, demonstrating the durability of the treatment effects. Limitations include the absence of a placebo-controlled group and lack of physiological baseline measures. Despite these limitations, results point to the need for future trials examining the clinical efficacy of trauma reactivation plus propranolol, as it has the potential to become a novel, cost- and time-effective treatment for PTSD.

Reactivating addiction-related memories under propranolol to reduce craving: A pilot randomized controlled trial

BACKGROUND The reconsolidation blocker propranolol abolishes alcohol and drug-seeking behavior in rodents and attenuates conditioned emotional responses to drug-cues in humans in experimental settings. This suggests a role for its use in the treatment of substance dependence. In this translational pilot study, we explored the feasibility and efficacy of this procedure as an adjunct treatment for addiction. We hypothesized that guided addiction-related memory reactivation under propranolol would significantly attenuate tonic craving, a central element in relapse following addiction treatment. METHODS Seventeen treatment-seeking adults diagnosed with substance dependence were randomized to receive double-blind propranolol (n = 9) or placebo (n = 8) on six occasions prior to reading a personalized script detailing a drug-using experience. The primary outcome measure was self-reported craving intensity. RESULTS After controlling for baseline craving scores, intent-to-treat analysis revealed a time by group interaction, F(1, 14) = 5.68, p = .03, η(2) = 0.29; craving was reduced in the propranolol-treated group (Cohens d = 1.40, p < .05) but not in the placebo group (d = 0.06, n.s.). LIMITATIONS The usual limitations related to small sample size and the lack of a follow-up apply here. CONCLUSION Drug-related memory reactivation under propranolol can subsequently reduce craving among substance-dependent individuals. Considering the relapse rate among individuals treated for substance dependence, our study highlights the feasibility of, and need for, more comprehensive trials of this treatment approach.

Does reconsolidation occur in humans: a reply

Schiller and Phelps (2011) have provided a thoughtful and comprehensive review in the May issue of Frontiers in Behavioral Neurosciences entitled, “Does reconsolidation occur in humans?” This scholarly paper captures many of the challenges in translating the animal research on reconsolidation to humans. We agree with their main argument that there is little published evidence in humans that meets one important reconsolidation criterion, namely, that the memory-weakening treatment should be administered after the memory reactivation, so as not to influence the preceding memory retrieval process. However, it is unclear whether pre-reactivation propranolol significantly hampers memory retrieval. On the basis of this uncertainty, Schiller and Phelps go on to suggest that the memory impairing effects of pre-reactivation propranolol (e.g., Kindt et al., 2009; Brunet et al., 2011) must be explained by some process other than reconsolidation. Such a conclusion appears illogical, because if propranolol does not impair retrieval sufficiently to preclude reconsolidation, then blockade of memory reconsolidation remains a viable explanation for pre-reactivation propranolols memory-weakening action. Indeed, the ultimate evidence for successful memory retrieval is measured during reactivation (e.g., freezing behavior in rodent fear conditioning, GSR in human fear conditioning, etc.). Therefore, any impairment of retrieval should be detected. Moreover, as shown recently by Debiec et al. (2011) immediate post-retrieval beta-adrenergic receptor stimulation enhances reconsolidation of fear conditioning in the amygdala. In this scenario, administration of propranolol following memory retrieval (which results in arousal and noradrenergic stimulation) may be too late to be effective. So, a parsimonious explanation is that pre-reactivation propranolol did block reconsolidation to some extent in the above-mentioned studies. Pre-reactivation propranolol studies (and other studies with a similar design) ought to be pursued vigorously because, irrespective of how the memory impairing effect is obtained, they offer the prospect of a novel approach to treating mental disorders that have at their core an emotional, usually traumatic, memory. Although Schiller and Phelps acknowledge some of the challenges of blocking reconsolidation using pharmacological means in humans, it is important to note the reasons for this difficulty. In animals, reconsolidation (i.e., protein synthesis) is believed to begin 3–10 min after memory reactivation (Monfils et al., 2009). Most of it appears to take place within the first 2 h (Przybyslawski et al., 1999) and to be over by the sixth hour (Duvarci and Nader, 2004). Considering that oral propranolol takes about 90 min to reach its peak bioavailability in human blood (Marino, 1987); and considering that only a fraction of this drug will eventually cross the blood–brain barrier to be available to exert the necessary effect, protocols that use post-reactivation propranolol are vulnerable to yielding negative results because not enough protein synthesis will have been blocked by the time the drug reaches its full effect in the human brain. Since conducting our proof-of-concept study in posttraumatic stress disorder (PTSD; Brunet et al., 2008), which used post-reactivation propranolol, we have opted to use pre-reactivation propranolol in an attempt to develop what we hope will be a more potent therapeutic protocol (see Brunet et al., 2011). It is unfortunate that this type of protocol does not meet an important scientific criterion for studies that use it to be labeled as genuine “reconsolidation” studies, but this is the price to pay for conducting sound translational research in patients. Schiller et al. (2010) are to be commended for their efforts to devise a human protocol that circumvents the problems associated with pharmacological blockade of reconsolidation by incorporating new material into a destabilized old memory, rather than simply blocking its reconsolidation. However, they have yet to show that such an approach is sufficiently potent to help patients overcome their psychological symptoms stemming from a traumatic emotional memory.

Variables associated with general practitioners taking on serious mental disorder patients

BackgroundAs part of community-based initiatives to strengthen integrated care and promote patient recovery, GPs are asked to play a greater part in treating serious mental disorder (SMD) patients. All current healthcare reforms favour the reinforcement of primary care. More information on enhancing the role of GPs in mental health would benefit policymakers, especially as regards SMD patients, where little research has been published as yet. This article assesses variables associated with GPs taking on SMD patients.MethodsThe study, encompassing multiple sites, is based on a sample of 398 GPs, representative of the GP population in the Canadian province of Quebec. GPs were asked to answer a 143-item questionnaire on their socio-demographic and clinical practice profiles, patient characteristics, perceived inter-professional relationships and quality of care. Descriptive, bivariate and multivariate analyses were performed.ResultsOur data highlighted that GPs currently followed up only a minority of SMD patients on a continuous basis and far fewer for both physical and mental health problems. A linear regression model that accounts for 43% of the variance was generated. The best variables associated positively with GPs taking on SMD patients were: frequency of referrals for joint follow-up with other resources, and involvement in post-hospitalization follow-up. Conversely, lack of expertise in mental health (related in our model to frequency of mental disorder patient transfer due to insufficient mental health training) is associated with a lower incidence of GPs taking on patients.ConclusionAs advocated in current healthcare reforms, our study confirms the need to promote greater GP involvement in integrated care models and enhance their training in mental health – thereby helping to reverse the trend among GPs of transferring SMD patients to specialized care. Patients with stable SMDs ought to have the same care access as the general population.