Manuel Trujillo

Brain SPECT Imaging in Complex Psychiatric Cases: An Evidence-Based, Underutilized Tool

Over the past 20 years brain Single Photon Emission Computed Tomography (SPECT) imaging has developed a substantial, evidence-based foundation and is now recommended by professional societies for numerous indications relevant to psychiatric practice. Unfortunately, SPECT in clinical practice is utilized by only a handful of clinicians. This article presents a rationale for a more widespread use of SPECT in clinical practice for complex cases, and includes seven clinical applications where it may help optimize patient care.

Network therapy for cocaine abuse: use of family and peer supports.

Cocaine-dependent subjects were treated by psychiatric residents in a 24-week sequence of Network Therapy. This approach, developed for practitioners in solo practice, employs a cognitive-behavioral orientation in sessions with family and peers as well as in individual sessions. Of 47 subjects, 73% of all observed weekly urines were negative for cocaine, and 20 (45%) of the subjects had negative toxicologies in the last 3 scheduled samples. A positive outcome was associated with the number of network (but not individual) sessions attended and completion of the full treatment sequence. Results suggest the utility of Network Therapy, even in the hands of relatively naive therapists.

A Treatment Algorithm for Attention Deficit Hyperactivity Disorder in Cocaine-Dependent Adults: A One-Year Private Practice Study with Long-Acting Stimulants, Fluoxetine, and Bupropion

A subgroup of adults in private treatment for cocaine dependence in remission reported a therapeutic effect from cocaine during the initial phases of cocaine addiction and, also, met DSM-IV criteria for ADHD. We report evidence that study subjects probably medicated their ADHD symptoms with cocaine and describe a 1-year treatment algorithm featuring long-acting stimulants that was effective in the management of their ADHD and cocaine dependence. Nineteen stable patients in full remission from all substance dependence were entered into an open label, prospective, treatment trial for ADHD. The treatment schedule consisted of the progressive introduction-and discontinuation of ineffective medication-of each of several medications in the following order: fluoxetine, bupropion, pemoline, sustained-release methylphenidate, dextroamphetamine spansules, and methamphetamine gradumets. Treatment of ADHD was successful. Several treatment regimens, especially those including long-acting stimulants, alone or in combination with other agents, were highly effective. All but 1 of the 19 subjects had a fully effective response for at least 1 full year. Mean UTAH scale scores were 7.4 before any medications were administered and 1.6 at the end of the study. Treatment proved successful in suppressing ADHD symptoms, with minimal cocaine slips or side effects.

Specific Ways Brain SPECT Imaging Enhances Clinical Psychiatric Practice

Abstract Our objective was to ascertain in a prospective case series how often brain single photon emission computed tomography (SPECT) neuroimaging adds relevant information for diagnosis and/or treatment beyond current standard assessment tools in complex psychiatric cases. Charts of 109 consecutively evaluated outpatients from four psychiatrics clinics that routinely utilize SPECT imaging for complex cases were analyzed in two stages. In stage one, psychiatrists reviewed detailed clinical histories, mental status exams, and the Structured Clinical Interview for DSM-IV, but not the results of SPECT studies, assigned a diagnosis based on DSM-IV criteria, and then developed a comprehensive treatment plan. In stage two, evaluators were given access to the SPECT studies for each patient. The addition of SPECT modified the diagnosis or treatment plan in 78.9% (n = 86; rated level 2 or 3 change) of cases. The most clinically significant changes were undetected brain trauma (22.9%), toxicity patterns (22.9%) and the need for a structural imaging study (9.2%). Specific functional abnormalities were seen as follows that potentially could impact treatment: temporal lobe dysfunction (66.1%) and prefrontal hypoperfusion (47.7%). SPECT has the potential to add clinically meaningful information to enhance patient care beyond current assessment tools in complex or treatment resistant cases.

Educating psychiatry residents about cultural aspects of care: A qualitative study of approaches used by U.S. Expert faculty

BACKGROUND/OBJECTIVE Almost no literature compares current approaches to teaching cultural issues across U.S. psychiatry residency programs; the authors addressed this comparison. METHODS The authors administered semistructured interviews of 20 instructors with substantial experience in the teaching of cultural issues in U.S. psychiatry residency programs, regarding the content, teaching techniques, institutional context, and evaluation of their curricula over time. RESULTS Approaches varied according to the local populations served and the background of the instructors, all of whom were either cross-trained in social sciences and humanities or were themselves ethnic, racial, or sexual minorities. Common themes emerged, including the use of experiential approaches, the lack of integration of cultural issues into clinical supervision or courses on other topics, and the absence of formal course evaluation. DISCUSSION Findings indicate a need for integration of cultural concepts into a variety of settings throughout residency, for development of faculty who are cross-trained in social sciences and humanities, and for curriculum-evaluation strategies.

Public Psychiatry Fellowships: A Developing Network of Public-Academic Collaborations

In response to the expanding public behavioral health care system, a network of 15 public-community psychiatry fellowships has developed over the past six years. The fellowship directors meet yearly to sustain and develop fellowships to recruit and retain psychiatrists in the public sector. This column describes five types of public-academic collaborations on which the fellowships are based. The collaborations focus on structural and fiscal arrangements; recruitment and retention; program evaluation, program research, and policy; primary care integration; and career development. These collaborations serve to train psychiatrists who will play a key role in the rapidly evolving health care system.

Evaluation of a Model for the Treatment of Combined Mental Illness and Substance Abuse: The Bellevue Model for Peer-Led Treatment in Systems Change

Abstract The present study evaluated a model program at Bellevue Hospital Center incorporating a peer-led self-help (PLSH) approach which can be applied to bring about systems-level change in a variety of settings where persons with dual diagnosis are encountered. A total of 461 consecutive MICA inpatient admissions were evaluated to compare the PLSH unit with two standard psychiatric units. The PLSH program was associated with a higher rate of acceptance of aftercare referral (93% vs. 74%) and aftercare attendance (52% vs. 30%) among patients with no prior psychiatric hospitalizations (N = 111). In addition, the PLSH program appeared to benefit chronically impaired MICA patients (N = 350) or those with a history of prior psychiatric hospitalizations, as they were more likely to accept referral to aftercare treatment than were chronic patients discharged from the standard psychiatric units (96% vs. 81%). Such a program, when more widely applied, could yield decreased recidivism and considerably lower medical, psychiatric, and economic cost.

Gender-Based Cerebral Perfusion Differences in 46,034 Functional Neuroimaging Scans.

BACKGROUND Studies have reported that females have widespread increases in regional cerebral blood flow, but the studies were relatively small and inconsistent. OBJECTIVE Here we analyzed a healthy and a very large clinical psychiatric population to determine the effect of gender, using single photon emission computed tomography (SPECT). METHODS Whole brain and region of interest (ROI) gender differences were analyzed in a total of 46,034 SPECT scans at baseline and concentration. The sample included 119 healthy subjects and 26,683 patients (60.4% male, 39.6% female); a subset of 11,587 patients had complete diagnostic information. A total of 128 regions were analyzed according to the AAL Atlas, using ROI Extract and SPSS statistical software programs, controlling for age, diagnoses, and correcting for multiple comparisons. RESULTS Compared to males, healthy females showed significant whole brain (p < 0.01) and ROI increases in 65 baseline and 48 concentration regions (p < 0.01 corrected). Healthy males showed non-significant increases in 9 and 22 regions, respectively. In the clinical group, there were widespread significant increases in females, especially in the prefrontal and limbic regions, and specific increases in males in the inferior occipital lobes, inferior temporal lobes, and lobule 7 and Crus 2 of the cerebellum. These findings were replicated in the subset of 11,587 patients with the effect of diagnoses removed. CONCLUSIONS Our results demonstrated significant gender differences in a healthy and clinical population. Understanding these differences is crucial in evaluating functional neuroimaging and may be useful in understanding the epidemiological gender differences among psychiatric disorders.