Marcia L. Verduin

Symptom Improvement in Co-Occurring PTSD and Alcohol Dependence

This study investigated the temporal course of improvement in PTSD and alcohol dependence symptoms among individuals participating in a 12-week outpatient treatment study. Participants were 94 individuals with comorbid PTSD and alcohol dependence enrolled in a double-blind, placebo-controlled medication trial. Outcome measures included PTSD symptoms (as measured by the Clinician Administered PTSD Scale, Impact of Events Scale, and Civilian Mississippi Scale for PTSD) and alcohol use severity (as measured by the Time Line Follow Back). Study completion rates were significantly higher for individuals who demonstrated improvement in both disorders. Improvements in PTSD had a greater impact on improvement in alcohol dependence symptoms than the reciprocal relationship. Improvement in hyperarousal PTSD symptoms, in particular, was related to substantially improved alcohol use. Examination of the temporal course of symptom improvement revealed that alcohol symptoms tended to start improving either before or in conjunction with PTSD symptoms. Although preliminary in nature, these findings suggest that co-occurring PTSD symptoms may have a strong impact on alcohol dependence treatment outcome, and that PTSD treatment may be important to optimizing outcomes for patients with comorbid PTSD and alcohol dependence.

Pharmacotherapy of Comorbid Mood, Anxiety, and Substance Use Disorders

Mood and anxiety disorders commonly co-occur with substance use disorders. Exploration of the neurobiology of substance use disorders and mood and anxiety disorders have found that the neural circuitry in mood, anxiety, and substance use disorders is clearly overlapping. These discoveries have encouraged the exploration of a number of pharmacotherapeutic agents in the treatment of co-occurring mood, anxiety, and substance use disorders. In this article, recent data on the pharmacotherapeutic treatment of mood and anxiety disorders in individuals with substance use disorders are reviewed. Some of the barriers to the use of pharmacotherapy in individuals with substance use disorders are discussed.

Independent Predictors for Lifetime and Recent Substance Use Disorders in Patients with Rapid-Cycling Bipolar Disorder: Focus on Anxiety Disorders

We set out to study independent predictor(s) for lifetime and recent substance use disorders (SUDs) in patients with rapid-cycling bipolar disorder (RCBD). Extensive Clinical Interview and Mini-International Neuropsychiatric Interview were used to ascertain DSM-IV Axis I diagnoses of RCBD, anxiety disorders, and SUDs. Data from patients enrolling into four similar clinical trials were used. Where appropriate, univariate analyses with t-test or chi-square were applied. Stepwise logistic regression was used to examine the relationship among predictor variables and lifetime and recent SUDs. Univariate analysis showed that patients with co-occurring anxiety disorders (n = 261) had significantly increased rates of lifetime (odds ratio [OR]= 2.1) and recent (OR = 1.9) alcohol dependence as well as lifetime (OR = 3.4) and recent (OR = 2.5) marijuana dependence compared to those without co-occurring anxiety disorder (n = 303). In logistic regression analyses, generalized anxiety disorder (GAD) was associated with increased risk for lifetime SUDs (OR = 2.34), alcohol dependence (OR = 1.73), and marijuana dependence (OR = 3.36) and recent marijuana dependence (OR = 3.28). A history of physical abuse was associated with increased risk for lifetime SUDs (OR = 1.71) and recent marijuana dependence (OR = 3.47). Earlier onset of first mania/hypomania was associated with increased risk for lifetime SUDs (5% per year), and recent marijuana dependence (12% per year) and later treatment with a mood stabilizer were also associated with increased risk for recent SUDs (8% per year). Positive associations between GAD, later treatment with a mood stabilizer, and early childhood trauma and history of SUDs suggest that adequate treatment of comorbid anxiety, early treatment with a mood stabilizer, and prevention of childhood trauma may reduce the risk for the development of SUDs in patients with bipolar disorder.

Gabapentin in Comorbid Anxiety and Substance Use

Recent reports promote the efficacy of gabapentin for both anxiety and substance use disorders (SUDs).1, 2 We report on an individual with polysubstance dependence and social phobia who had decreas...

Computer simulation games as an adjunct for treatment in male veterans with alcohol use disorder

This study examined the impact of a computer simulation designed to provide the opportunity for individuals with alcohol use disorders (AUDs) to practice relapse prevention skills. Participants were 41 male veterans enrolled in an intensive outpatient substance abuse treatment program. Participants were randomly assigned to either view educational slides about treatment for AUD or play a simulation videogame for eight sessions within 12 weeks. Participants were assessed at a 4-week follow-up visit. Outcome measures included relapse rates as well as ratings on the Obsessive Compulsive Drinking Scale (OCDS) and a custom-designed relapse prevention self efficacy scale. While rates of relapse did not differ between groups, those who played the game showed overall reductions in ratings on the OCDS, as well as higher ratings of self-efficacy at week 8, suggesting that the videogame simulation may be a useful adjunct to AUD treatment.

A Brief Examination of Integrated Care in Undergraduate Medical Education

ObjectiveThis study examines how behavioral and physical health are currently integrated in undergraduate medical education, both in the classroom and during clinical rotations.MethodsMembers of the Association of Directors of Medical Student Education in Psychiatry (n = 215) were invited to complete a short survey on the integration of physical and behavioral health at their institution.ResultsIn addition to undergraduate medical courses traditionally taught by psychiatrists, behavioral science topics are often addressed in neurology, reproduction, and doctoring courses. During clinical rotations, behavioral health topics are most likely taught during the family medicine clerkship and, conversely, least likely during the surgery clerkship; furthermore, behavioral health topics are much less likely to be taught by psychiatrists during clinical rotations.ConclusionsIntegration of behavioral and physical health in medical education is beginning to occur in a meaningful context.

New directions in medical education related to psychiatry.

Abstract The 100-year anniversary of the Flexner report provides an opportunity to reflect on the future of medical education. We will consider the legacy of the original report, the centenary follow up to that report and consider how these, in concert with emerging learning theories, will influence medical education. We first provide a brief overview of the original Flexner report and review the recommendations of the 2010 centenary follow up to the report. We then discuss some of the major developments in learning theory and consider how they have influenced medical education. In general, there has been a gradual shift from passive to active methods, spurred in part by constructivist theories of learning. Many of the attitudes and skills required are particular strengths of the psychiatrist, making psychiatric educators particularly suitable to lead curricular change. Although much literature is devoted to determining the ‘best’ educational method, we take an ecumenical approach, suggesting that the various pedagogical approaches are all legitimate educational tools from which to choose. Each has its strength and limitations, and when designing a curriculum we should consider these when making pedagogical choices. We finish with some practical advice for those contemplating curricular change.

An Open-Label Trial of Aripiprazole Treatment in Dual Diagnosis Individuals: Safety and Efficacy

This open-label study evaluated the safety and efficacy of aripiprazole in the treatment of 20 patients with co-morbid schizophrenia, schizoaffective disorder, or bipolar disorder and alcohol, cocaine, and/or marijuana use disorders. Primary outcomes were substance use, measured by the Timeline Followback, and score on the Clinical Global Impression scale for psychiatric and substance use symptoms. The data suggest that aripiprazole may reduce substance use and improve psychiatric symptoms in patients with co-morbid disorders; however, limitations are noted. Subsequent randomized studies are needed to further explore these findings.

Improving the Recruitment of Medical Students into Psychiatry.

The drop in the number of graduating US seniors entering psychiatry to a decade low of 3.9% in 2012 [1] caught the attention of our field with a renewed focus on recruitment into psychiatry. Interest in recruitment is not new nor is it unique to the USA [2–4]. In fact, the World Psychiatric Association and the Royal College of Psychiatrists have both created specific action plans to increase recruitment in the field [2, 5]. Studies aimed at identifying factors that draw students to psychiatry date back at least 50 years, when post-World War II recruitment, which peaked at 10% of graduates entering psychiatry per year, began to decline [6]. Recruitment has been cyclical in nature since that time [7], and over the past decade, recruitment rates have hovered around just 3.9–4.9% [1, 8–10], leading many to express concern for the future of our field. On the other hand, recent data from the National Resident Matching Program (NRMP) suggests that we are doing quite well in terms of attracting new psychiatrists. In 2016, the fill rate for psychiatry residency positions reached a decade high of 99.2% [11], with only 12 positions remaining unfilled in the entire country. This is even more significant when considering that the number of available residency positions in psychiatry has increased by nearly 25% over the past 5 years [11]. This begs the question of whether there can be a recruitment crisis in psychiatry when nearly all residency positions were filled in the 2016Match. A closer look at the data, however, reveals an interesting trend. Of the 1384 positions available, only 850 (61%) were filled by US seniors [11].We are fortunate to have a strong pool of highly qualified international medical graduates (IMGs) to fill these positions in psychiatry, and it is certainly to the benefit of our profession to match the most capable applicants, whether educated in the USA or abroad, to our residency programs. This data does raise the question, however, of whether we are somehow falling short in attracting students from our own medical schools—those in which we teach and practice—to psychiatry. In addition, growing concerns about the expanding US population in proportion to the number of psychiatrists in this country [12] have led to the classification of psychiatry as a shortage specialty [13]. Add to this the noted “graying” of the field, with nearly 60% of active psychiatrists reported to be over the age of 55 [14], and the shortage becomes even more significant. In fact, according to the Association of American Medical Colleges (AAMC), there will be a deficit of 22,200 to 32,600 psychiatrists by the year 2025 [13]. Given this, even if we succeed in attracting a sufficient number of US seniors to psychiatry, we will still fall far short of the predicted need. The recruitment crisis in psychiatry is real, and in order to solve it, we must not only increase recruitment of US seniors but also advocate for an increase in the number of psychiatry residency positions. Expansion of residency positions is a major hurdle for the field, given the complexity of graduate medical education (GME) funding and residency caps, and will likely require a restructuring of the current funding system. Current options for expanding GME positions include the Veterans Access, Choice, and Accountability Act (VACAA) of 2014, which calls for the Department of Veterans Affairs to increase the number of GME positions by up to 1500 over a 5-year period [15]; state funding agencies (e.g., Medicaid incentive packages), which may have special sources of funding related to workforce shortages; and “new” teaching hospitals that are eligible for cap building with new federal CMS funding. Expansion of residency positions will only take us so far, however, if we are not recruiting adequate numbers of * Marcia L. Verduin marcy.verduin@ucf.edu

Assessment of Club Drug Use in a Treatment-Seeking Sample of Individuals with Marijuana Dependence

Club drug use is becoming increasingly popular in the United States and has been associated with chronic psychiatric symptoms and neuropsychological abnormalities. Patterns of club drug use and characteristics of club drug users are not homogeneous. Thus, treatment-seeking marijuana-dependent individuals may have a differential pattern of club drug use. Baseline assessments collected from 55 individuals participating in a pharmacological treatment study for marijuana dependence were examined. Individuals completed a 16-item self-report questionnaire assessing club drugs used, frequency and patterns of use, problems associated with use, and reasons for use. Subjects were primarily male (87.3%) and Caucasian (81.8%), with a mean age of 32.1 (+/-9.1 years). As expected, a large number of individuals had used ecstasy (75%). However, LSD and methamphetamine use was also reported by many users (82.5% and 47.5% respectively), with many individuals reporting the use of more than one club drug. Notably, 31.6% of individuals reported tolerance to club drugs. These results emphasize the significant co-occurrence of club drug use in marijuana-dependent individuals. This appears to be the first study to report on club drug use in treatment-seeking marijuana-dependent individuals. Clinical implications and directions for future research are discussed.