Hippocampal subfield viscoelasticity in amnestic mild cognitive impairment evaluated with MR elastography

Hippocampal subfields (HCsf) are brain regions important for memory function that are vulnerable to decline with amnestic mild cognitive impairment (aMCI), which is often a preclinical stage of Alzheimer's disease. Studies in aMCI patients often assess HCsf tissue integrity using measures of volume, which has little specificity to microstructure and pathology. We use magnetic resonance elastography (MRE) to examine the viscoelastic mechanical properties of HCsf tissue, which is related to structural integrity, and sensitively detect differences in older adults with aMCI compared to an age-matched control group. Group comparisons revealed HCsf viscoelasticity is differentially affected in aMCI, with CA1-CA2 and DG-CA3 exhibiting lower stiffness and CA1-CA2 exhibiting higher damping ratio, both indicating poorer tissue integrity in aMCI. Including HCsf stiffness in a logistic regression improves classification of aMCI beyond measures of volume alone. Additionally, lower DG-CA3 stiffness predicted aMCI status regardless of DG-CA3 volume. These findings showcase the benefit of using MRE in detecting subtle pathological tissue changes in individuals with aMCI via the HCsf particularly affected in the disease.

Medicolegal Implications of Mild Neurocognitive Disorder

INTRODUCTION

The syndromes of mild cognitive impairment (MCI) or mild neurocognitive disorder (MiND), often prodromal to dementia (Major Neurocognitive Disorder), are characterized by acquired clinically significant changes in one or more cognitive domains despite preserved independence. Mild impairment has significant medicolegal consequences for an affected person and their care system. We review the more common etiologies of MiND and provide a systematic review of its medicolegal implications.

METHODS

We conducted a systematic review of the peer-reviewed English literature on medicolegal aspects of MCI or MiND using comprehensive search terms and expanding our review to include sources cited by these reports.

RESULTS

Impairment of memory, executive function, social cognition, judgment, insight or abstraction can alter an individual's abilities in a variety of areas that include decision making, informed consent, designation of a surrogate decision-maker such as a health care proxy, understanding and management of financial affairs, execution of a will, or safe driving.

CONCLUSION

Even mild cognitive impairment can have significant behavioral consequences. Clinicians can assist care partners and persons with MCI or MiND by alerting them to the medicolegal concerns that often accompany cognitive decline. Early recognition and discussion can help a care system manage medicolegal risk more effectively and promote thoughtful advance planning.

Late Life Depression: The Essentials and the Essential Distinctions

Late life depression (LLD), a familiar syndrome, is not differentiated in the DSM-5. LLD can resemble depressive syndromes in younger adults but it differs in demographic characteristics, phenomenology, prognosis, treatment, suicide risk, relationship to other disorders, and etiology. Older depressed adults often present with fewer major depressive symptoms, less emphasis on mood disturbance, greater preoccupation with somatic or psychotic symptoms, and misleading cognitive deficits. LLD's relationships with medical and neurocognitive symptoms and with inflammatory and immune factors are complex. Formal screening tools and biopsychosocial assessment informs diagnosis and treatment. Evidence supports the effectiveness of lifestyle interventions, several psychotherapies, and a variety of somatic treatment approaches. Comorbid medical disorders must be taken into account when planning treatment. In this article, the authors describe the characteristics of LLD, present an approach to assessment and management, and recommend that future DSM editions include a new specifier to differentiate LLD from other depressive syndromes.

The "Counseling+" Roles of the Speech-Language Pathologist Serving Older Adults With Mild Cognitive Impairment and Dementia From Alzheimer's Disease

Purpose

Persons with dementia and mild cognitive impairment (MCI) are major consumers of services provided by speech-language pathologists (SLPs). These services include not only direct assessment and treatment of communication and swallowing but also counseling, collaboration, prevention, and wellness. These "counseling+" activities can be especially challenging for SLPs to deliver because of the lack of evidence, as well as the complex nature of Alzheimer's disease (AD) and other conditions that cause MCI and dementia.

Method

This tutorial is written by a speech-language pathologist, a neuropsychologist, and a geriatric psychiatrist to provide education, resources, and recommendations for SLPs delivering counseling+ activities to patients with MCI and dementia from AD and related disorders.

Results and Conclusions

We describe counseling+ activities across the continuum of care ranging from educating and conducting cognitive screenings with adults experiencing age-related cognitive decline to supporting end-of-life wishes. Because of their expertise in communication, SLPs can provide an array of important leading and supporting services to patients, their family, and other health care professionals on the care team, such as providing patients with appropriate feedback following a cognitive screening and helping caregivers identify the communicative intent of a responsive behavior. The demand for SLP services for patients with MCI and dementia will grow significantly over the next few decades, necessitating more systematic research and clinical evidence in this area.

Cause for Concern: Behavioral and Psychological Symptoms of Dementia in Delaware's Long-Term Care Facilities

INTRODUCTION

Much of the suffering and expense associated with treatment of persons with dementia (Major Neurocognitive Disorder) arises from associated noncognitive behavioral and psychological symptoms of dementia (BPSD). Although a consensus on the prevalence of BPSD is lacking, evidence suggests that most people with dementia will manifest one or more of these symptoms during the disorder's progression. BPSD raise the cost of care by leading to more frequent emergency room visits, more and longer hospitalizations, and earlier admission to long-term care facilities (LTCF). Treatment of BPSD presents a stressful challenge in LTCFs. We sought to investigate the care burden of BPSD in Delaware's LTCFs and to gather data that can inform management approaches.

METHODS

Using REDCap, we created an anonymous cross-sectional survey designed for completion by LTCF administrators. The Delaware Health Care Facilities Association (DHCFA) and Delaware's Division of Services for Aging and Adults with Physical Disabilities (DSAAPD) encouraged participation. A link to the survey was emailed to the administrators of 81 facilities in Delaware. The resulting data were evaluated using descriptive statistics.

RESULTS

Forty-four of the 81 facilities surveyed opened the survey link. Thirty-eight facilities answered at least some of the questions, and 19 surveys were fully completed. The reported average prevalence of BPSD among Delaware LTCF residents with dementia was 49.3% (SD 28.9). The five most frequently reported BPSD symptoms were anxiety, agitation, wandering, dysphoria/depression, and appetite/eating abnormalities. All facilities reported employing a spectrum of pharmacologic and non-pharmacologic management strategies. Twenty-two of 24 respondents (91.7%) reported that behavioral health consultation was available at their facilities and 18 of 20 respondents (90.0%) indicated that they provided training on how to manage residents with BPSD.

CONCLUSION

BPSD are a pervasive concern among Delaware's LTCFs. LTCFs may benefit from the development of training programs and dissemination of treatment guidelines incorporating evidence-based interventions and their implementation in managing BPSD to improve care, decrease stress on residents and caregivers, and reduce some avoidable health care costs.

Effect of Aging on the Viscoelastic Properties of Hippocampal Subfields Assessed with High-Resolution MR Elastography

Age-related memory impairments have been linked to differences in structural brain parameters, including the integrity of the hippocampus (HC) and its distinct hippocampal subfields (HCsf). Imaging methods sensitive to the underlying tissue microstructure are valuable in characterizing age-related HCsf structural changes that may relate to cognitive function. Magnetic resonance elastography (MRE) is a noninvasive MRI technique that can quantify tissue viscoelasticity and may provide additional information about aging effects on HCsf health. Here, we report a high-resolution MRE protocol to quantify HCsf viscoelasticity through shear stiffness, μ, and damping ratio, ξ, which reflect the integrity of tissue composition and organization. HCsf exhibit distinct mechanical properties-the subiculum had the lowest μ and both subiculum and entorhinal cortex had the lowest ξ. Both measures correlated with age: HCsf μ was lower with age (P < 0.001) whereas ξ was higher (P = 0.002). The magnitude of age-related differences in ξ varied across HCsf (P = 0.011), suggesting differential patterns of brain aging. This study demonstrates the feasibility of using MRE to assess HCsf microstructural integrity and suggests incorporation of these metrics to evaluate HC health in neurocognitive disorders.

Machine Learning Enhances the Efficiency of Cognitive Screenings for Primary Care

BACKGROUND

Incorporation of cognitive screening into the busy primary care will require the development of highly efficient screening tools. We report the convergence validity of a very brief, self-administered, computerized assessment protocol against one of the most extensively used, clinician-administered instruments-the Montreal Cognitive Assessment (MoCA).

METHOD

Two hundred six participants (mean age = 67.44, standard deviation [SD] = 11.63) completed the MoCA and the computerized test. Three machine learning algorithms (ie, Support Vector Machine, Random Forest, and Gradient Boosting Trees) were trained to classify participants according to the clinical cutoff score of the MoCA (ie, < 26) from participant performance on 25 features of the computerized test. Analysis employed Synthetic Minority Oversampling TEchnic to correct the sample for class imbalance.

RESULTS

Gradient Boosting Trees achieved the highest performance (accuracy = 0.81, specificity = 0.88, sensitivity = 0.74, F1 score = 0.79, and area under the curve = 0.81). A subsequent K-means clustering of the prediction features yielded 3 categories that corresponded to the unimpaired (mean = 26.98, SD = 2.35), mildly impaired (mean = 23.58, SD = 3.19), and moderately impaired (mean = 17.24, SD = 4.23) ranges of MoCA score ( F = 222.36, P < .00). In addition, compared to the MoCA, the computerized test correlated more strongly with age in unimpaired participants (ie, MoCA ≥26, n = 165), suggesting greater sensitivity to age-related changes in cognitive functioning.

CONCLUSION

Future studies should examine ways to improve the sensitivity of the computerized test by expanding the cognitive domains it measures without compromising its efficiency.

A cross-validation Delphi method approach to the diagnosis and treatment of personality disorders in older adults

INTRODUCTION

The Delphi method is a consensus-building technique using expert opinion to formulate a shared framework for understanding a topic with limited empirical support. This cross-validation study replicates one completed in the Netherlands and Belgium, and explores US experts' views on the diagnosis and treatment of older adults with personality disorders (PD).

METHODS

Twenty-one geriatric PD experts participated in a Delphi survey addressing diagnosis and treatment of older adults with PD. The European survey was translated and administered electronically.

RESULTS

First-round consensus was reached for 16 out of 18 items relevant to diagnosis and specific mental health programs for personality disorders in older adults. Experts agreed on the usefulness of establishing criteria for specific types of treatments. The majority of psychologists did not initially agree on the usefulness of pharmacotherapy. Expert consensus was reached following two subsequent rounds after clarification addressing medication use.

CONCLUSIONS

Study results suggest consensus among regarding psychosocial treatments. Limited acceptance amongst US psychologists about the suitability of pharmacotherapy for late-life PDs contrasted with the views expressed by experts surveyed in Netherlands and Belgium studies.

Feasibility of a web-based survey of hallucinations and assessment of visual function in patients with Parkinson's disease

Background

Patients with Parkinson’s disease (PD) experience visual hallucinations, which may be related to decreased contrast sensitivity (ie, the ability to discern shades of grey).

Objective

The objective of this study was to investigate if an online research platform can be used to survey patients with Parkinson’s disease regarding visual hallucinations, and also be used to assess visual contrast perception.

Methods

From the online patient community, PatientsLikeMe, 964 members were invited via email to participate in this study. Participants completed a modified version of the University of Miami Parkinson’s disease hallucinations questionnaire and an online vision test.

Results

The study was completed by 27.9% (269/964) of those who were invited: 56.9% of this group had PD (153/269) and 43.1% (116/269) were non-Parkinson’s controls. Hallucinations were reported by 18.3% (28/153) of the Parkinson’s group. Although 10 subjects (9%) in the control group reported experiencing hallucinations, only 2 of them actually described formed hallucinations. Participants with Parkinson’s disease with a mean of 1.75 (SD 0.35) and the control group with a mean of 1.85 (SD 0.36) showed relatively good contrast perception as measured with the online letter test (P=.07). People who reported hallucinations showed contrast sensitivity levels that did not differ from levels shown by people without hallucinations (P=.96), although there was a trend towards lower contrast sensitivity in hallucinators.

Conclusions

Although more Parkinson's responders reported visual hallucinations, a significant number of non-Parkinson's control group responders also reported visual hallucinations. The online survey method may have failed to distinguish between formed hallucinations, which are typical in Parkinson's disease, and non-formed hallucinations that have less diagnostic specificity. Multiple questions outlining the nature of the hallucinations are required. In a clinical interview, the specific nature of the hallucination would be further refined to rule out a vague description that does not indicate a true, formed visual hallucination. Contrary to previous literature, both groups showed relatively good contrast sensitivity, perhaps representing a ceiling effect or limitations of online testing conditions that are difficult to standardize. Steps can be taken in future trials to further standardize online visual function testing, to refine control group parameters and to take steps to rule out confounding variables such as comorbid disease that could be associated with hallucinations. Contacting subjects via an online health social network is a novel, cost-effective method of conducting vision research that allows large numbers of individuals to be contacted quickly, and refinement of questionnaires and visual function testing may allow more robust findings in future research.

Depression in later life: an overview with treatment recommendations

We have already entered a new, more exciting, and hopeful era in the treatment of late-life depression. The increasing numbers of older adults who are surviving to more advanced ages and the greater recognition of late-life depression’s prevalence and impact on quality of life emphasize how important it is to detect and treat this disorder. Our increasing repertoire of evidence-based psychotherapeutic, pharmacologic, and neurotherapeutic treatment interventions offers many treatment alternatives, allowing substantial individualization of treatment approach. Demonstration of the effectiveness of depression treatment in primary care suggests the feasibility of increasing our patients’ access to care. Growing appreciation of the pathophysiology of depression and its interrelationships with cognitive impairment may increase our ability to limit or delay certain aspects of cognitive impairment through more aggressive treatment of depression. Improved recognition and treatment of late-life depression holds great potential for improving physical and mental health in later life, reducing disability in later years, and improving quality of life.

A 60-year-old woman with mild memory impairment: review of mild cognitive impairment

Many older individuals experience or demonstrate cognitive impairment that is significantly abnormal for their age and education yet beneath the threshold for a diagnosis of dementia. This mild cognitive impairment causes minimal functional impairment and is often overlooked in clinical settings, yet affected individuals are at heightened risk for a range of adverse outcomes including conversion to dementia. The case of Ms E, a 60-year-old woman with mild memory impairment and white matter lesions on magnetic resonance imaging, provides an opportunity to consider the questions that face patient, family, and clinicians when mild cognitive symptoms prompt a search for diagnosis and management options. Discussion of her case reviews mild cognitive impairment with emphasis on an evidence-based approach to evaluation and treatment, including management of comorbid medical conditions, lifestyle changes, and pharmacotherapy.

Teaching collaboration between pharmacotherapist and psychotherapist

OBJECTIVE

Collaborative treatment, in which psychotherapy provided by one clinician is integrated with pharmacotherapy provided by another clinician, has been explored from various angles. This article addresses the teaching of collaborative pharmacotherapy to psychiatric residents.

METHOD

The author's observations derive from a selective review of the literature and from conclusions drawn from practicing and teaching collaborative therapy in a psychiatric residency program.

RESULTS

Limited formal attention has been given to defining the skills psychiatrists should acquire in order to collaborate effectively. The author describes the rationale for providing collaborative treatment, identifies the skill set that facilitates collaborative treatment, and outlines an approach to teaching and assessing these skills.

CONCLUSION

The practice of collaborative treatment is an important psychiatric role. The core skills of collaborative treatment should be explicitly taught and residents' competency in these skills should be evaluated in psychiatric training programs.

Treatment-resistant depression and the collaborative treatment relationship

Many depressed patients experience only limited improvement despite provision of appropriate therapies within a collaborative treatment arrangement (the integrated provision of psychotherapy and pharmacotherapy). In the interest of enhancing these patients' partial responses, it is valuable to examine the treatments provided and also the collaborative framework in which they are offered. The authors use vignettes to illustrate how each of several factors-the adequacy of treatment with each modality, behavioral impediments to response, compliance with treatments, recognition and appropriate matching of treatments to relevant concurrent diagnoses, and appropriate communication between collaborating clinicians-may affect treatment outcome. Recommendations are offered for clinicians engaging in a collaborative relationship, including attending carefully to the patients' comments about a complementary modality of treatment and the clinician delivering it, communicating useful information to the collaborating therapist, and being receptive to information that is offered by the collaborating therapist.

Antidepressant-induced sexual dysfunction: review, classification, and suggestions for treatment

Sexual function, an important component of quality of life, is often affected by antidepressant treatment. Reports associate antidepressant medications with a wide range of sexual disorders of desire, arousal, and orgasm, and with the occurrence of sexual pain. Fewer sexual dysfunctions have been reported with bupropion, nefazodone, and mirtazapine than with the monoamine-oxidase inhibitors, tricyclic antidepressants, selective serotonin-reuptake inhibitors, and venlafaxine. Sexual dysfunctions may occur in more than half of patients treated with selective serotonin-reuptake inhibitors, but patients may not readily divulge sexual information unless a clinician is knowledgeable and proactive in assessment. Once an antidepressant-induced sexual dysfunction is detected and its nature is characterized, an appropriate treatment intervention can be chosen in order to alleviate the sexual disorder and enhance treatment compliance. This review classifies antidepressant-induced sexual dysfunctions, discusses assessment and differential diagnosis, and describes currently reported treatment approaches.

Description of antipanic therapy in a prospective longitudinal study

The authors present a summary scale for assessing the percentage of patients in a large longitudinal study of panic disorder who received proven effective psychopharmacologic treatment. Such a scale provides a means for assessing and comparing somatic treatments of panic disorder across medication classes. The antipanic therapy levels were applied to data on medication treatment received by 492 patients participating in a naturalistic study and reflect psychopharmacologic treatment prescribed in 11 academic centers. Results show that among patients treated by psychiatrists at major teaching hospitals only 54% of the most symptomatic groups received optimal pharmacologic treatment. Among less symptomatic patients, who nonetheless met full criteria for panic disorder with or without agoraphobia, only 43% received maximal therapy.

Schizophrenia and the life cycle

We reframe the longitudinal treatment of persons with schizophrenia from the perspective of phases in adult development. This approach articulates the need for different interventions of varying intensities over the person's lifetime. The paper discusses the implications of an adult developmental perspective in managing pharmacologic treatment and psychosocial interventions, and in reallocating financial resources for improved long-term outcomes. This perspective is especially useful in the context of a comprehensive community mental health program permitting access to a continuum of services throughout the lifecycle.

SSRI-associated nocturnal bruxism in four patients

BACKGROUND

Nocturnal bruxism (tooth clenching and/or grinding during sleep) affects a significant proportion of the population. Its etiology remains uncertain, and no entirely satisfactory treatment is available.

METHOD

This is an observational report of four depressed individuals selected from one psychiatrist's practice within an urban hospital's psychopharmacology clinic. Psychiatric diagnoses were made according to DSM-III-R criteria. Nocturnal bruxism was determined on the basis of dental examination and/or self-reported nocturnal tooth clenching and/or grinding.

RESULTS

Four patients developed nocturnal bruxism within 2 to 4 weeks after initiation of treatment with fluoxetine or sertraline. Bruxism remitted in all patients after a decrease in antidepressant dosage (N = 1) or addition of buspirone (N = 3).

CONCLUSION

These observations, which should be confirmed by a controlled study, suggest an association between serotonin selective reuptake inhibitor (SSRI) treatment and the onset or exacerbation of nocturnal bruxism. In addition, they suggest that a decrease in SSRI dosage or the addition of buspirone may relieve SSRI-associated nocturnal bruxism.

The case for a services-based approach to payment for mental illness under national health care reform

In this position paper drafted by the committee on psychopathology of the Group for the Advancement of Psychiatry, the authors discuss merits and disadvantages of three different approaches to equitable coverage of mental illness: coverage for selected psychiatric diagnoses, coverage based on severity of impairment, and coverage of services. They believe that coverage of selected disorders has political appeal but is discriminatory and arbitrary; it is also impractical because clinicians may overdiagnose conditions covered by insurance and underdiagnose excluded conditions. Coverage based on severity of impairment, or disability, has similar limitations. The authors believe services should be the principal basis for coverage, as under general medical insurance. The approach is nondiscriminatory, and costs can be controlled through such means as managed care, changes in the payment system, or benefit design.

Fluoxetine-induced bradycardia and syncope in two patients

Fluoxetine appears to cause a low incidence of adverse cardiac effects. An uncommon but potentially hazardous effect of fluoxetine therapy, however, is bradycardia accompanied by faintness or syncope. The authors report two cases in which this adverse effect occurred. They hypothesize that the mechanism of bradycardia in these cases represents a direct central nervous system effect of increased serotonin on medullary cardiovascular regulation.

Comorbidity of personality disorders: two for the price of three

Clinicians who treat individuals with personality disorders must remain alert to the presence of concurrent mood disorders, anxiety disorders; or schizophrenia. Comorbid disorders can significantly affect a patient's presentation, treatment, and prognosis.

A strategy for the pharmacotherapy of personality disorders

Current research reveals that biological factors play an important role in shaping normal and disordered personality features. Judicious use of medications can facilitate the treatment of individuals with personality disorders.

An emergency psychiatry update

A review of trends in emergency psychiatry since 1981 indicates that the scope and complexity of the field have greatly increased. Clinicians have found it useful to identify patient groups with special assessment and treatment needs, including adolescents, the elderly, victims of rape and of domestic violence, and repeat visitors to the emergency service. The spread of AIDS requires greater medical attentiveness by psychiatric emergency clinicians, and two recreational substances of abuse, cocaine and inhalants, have become increasingly popular. The use of psychotropic drugs in the emergency room has received more attention, and new trends in rapid tranquilization are apparent. Also reviewed are current medicolegal controversies related to emergency room practice, findings on prediction and control of violence, and the use of the psychiatric emergency service as a training site.

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 consultant's 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 patient's 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.

Repeat visitors in the psychiatric emergency service: a critical review of the data

Repeat visitors to psychiatric emergency services constitute 7 to 18 percent of the total patients and account for up to a third of the visits. This frequently difficult-to-treat group has been described in six controlled and two uncontrolled studies. In a critical review of findings and methodology, the authors interpret and compare the available data about repeaters. Their major conclusions are that repeaters are more likely to lack social supports, to be currently in psychiatric treatment, and to have a chronic illness. Research approaches to further elucidate these patients' characteristics are suggested.

More than a gateway: the role of the emergency psychiatry service in the community mental health network

The authors describe how an emergency psychiatry service in an inner-city general hospital has been able to expand its functions and strengthen its ties to community mental health agencies. A major factor in helping the emergency unit build closer relationships with community agencies is its contract with the state to perform evaluations of all admissions to the state hospital psychiatric unit serving the catchment area. The emergency unit performs triage and provides backup for the agencies, coordinates the management of multi-agency cases, and holds weekly educational conferences for agency staff. Using case examples, the authors illustrate how unit and agency staff collaborate to ensure continuity of patient care.

DSM-III and the diagnosis of organic mental disorders

Among the many emergency patients who complain of behavioral symptoms, a significant proportion suffer from a physical illness manifesting as an organic mental disorder. Dementia and delirium should be considered in the presence of an impairment of orientation, alertness, or cognition. Effort is required to remain aware of the organic differential diagnoses of hallucinatory, delusional, amnestic, and affective disorders or of personality changes not associated with overt changes of sensorium or cognitive abilities. We review the DSM-III classification of organic mental disorders published by the American Psychiatric Association, and consider the usefulness of historical data, mental status examination, physical examination, laboratory investigations, and hospitalization in the differentiation of organic from functional disorders.

Methamphetamine abuse presenting as dysuria following urethral insertion of tablets

Foreign bodies are inserted into the male urogenital tract for a variety of motives, and patients may present with symptoms of dysuria, urinary retention, hematuria, discharge, or priapism. Concomitant psychopathology is seen frequently, necessitating a thorough psychiatric assessment with attention to other acts of self-mutilation, suicide attempts, psychosis, or substance abuse. We report the case of an abuser of methamphetamine who inserted a sustained-release form of medication into his urethra, with resulting mechanical and pharmacological trauma.