Slow Wave Sleep Deficits in the Flinders Sensitive Line Rodent Model of Depression: Effects of Medial Forebrain Bundle Deep-Brain Stimulation

Major Depressive Disorder (MDD) is an affective disorder typically accompanied by sleep disturbances. Deep brain stimulation (DBS) of the medial forebrain bundle (MFB) is an emerging intervention for treatment-resistant depression, but its effect on sleep has not been closely examined. Here we aimed to characterise sleep deficits in the Flinders sensitive line, an established rodent model of depression, and investigate the consequences of MFB stimulation on sleep-related phenotypes. Rats were implanted with bilateral stimulation electrodes in the MFB, surface electrodes to record electrocorticography and electromyography for sleep scoring and electrodes within the prelimbic cortex, nucleus accumbens (NAc) and dorsal hippocampus. Recordings of sleep and oscillatory activity were conducted prior to and following twenty-four hours of MFB stimulation. Behavioural anti-depressant effects were monitored using the forced swim test. Previously unreported abnormalities in the Flinders sensitive line rats were observed during slow wave sleep, including decreased circadian amplitude of its rhythm, a reduction in slow wave activity and elevated gamma band oscillations. Previously established rapid eye movement sleep deficits were replicated. MFB stimulation had anti-depressant effects on behavioural phenotype, but did not significantly impact sleep architecture; it suppressed elevated gamma activity during slow wave sleep in the electrocorticogram and prelimbic cortex signals. Diverse abnormalities in Flinders sensitive line rats emphasise slow wave sleep as a state of dysfunction in affective disorders. MFB stimulation is able to affect behaviour and sleep physiology without influencing sleep architecture. Gamma modulation may represent a component of antidepressant mechanism.

Time course changes to structural, mechanical and material properties of bone in rats after complete spinal cord injury

OBJECTIVE

Characterise the spatiotemporal trabecular and cortical bone responses to complete spinal cord injury (SCI) in young rats.

METHODS

8-week-old male Wistar rats received T9-transection SCI and were euthanised 2-, 6-, 10- or 16-weeks post-surgery. Outcome measures were assessed using micro-computed tomography, mechanical testing, serum markers and Fourier-transform infrared spectroscopy.

RESULTS

The trabecular and cortical bone responses to SCI are site-specific. Metaphyseal trabecular BV/TV was 59% lower, characterised by fewer and thinner trabeculae at 2-weeks post-SCI, while epiphyseal BV/TV was 23% lower with maintained connectivity. At later-time points, metaphyseal BV/TV remained unchanged, while epiphyseal BV/TV increased. The total area of metaphyseal and mid-diaphyseal cortical bone were lower from 2-weeks and between 6- and 10-weeks post-SCI, respectively. This suggested that SCI-induced bone changes observed in the rat model were not solely attributable to bone loss, but also to suppressed bone growth. No tissue mineral density differences were observed at any time-point, suggesting that decreased whole-bone mechanical properties were primarily the result of changes to the spatial distribution of bone.

CONCLUSION

Young SCI rat trabecular bone changes resemble those observed clinically in adult and paediatric SCI, while cortical bone changes resemble paediatric SCI only.

Improving mental health care transitions for children and youth: a protocol to implement and evaluate an emergency department clinical pathway

Background

While the emergency department (ED) is often a first point of entry for children and youth with mental health (MH) concerns, there is a limited capacity to respond to MH needs in this setting. Child MH systems are typically fragmented among multiple ministries, organizations, and providers. Communication among these groups is often poor, resulting in gaps, particularly in transitions of care, for this vulnerable population. The evidence-based Emergency Department Mental Health Clinical Pathway (EDMHCP) was created with two main goals: (1) to guide risk assessment and disposition decision-making for children and youth presenting to the ED with MH concerns and (2) to provide a streamlined transition to follow-up services with community MH agencies (CMHAs) and other providers. The purpose of this paper is to describe our study protocol to implement and evaluate the EDMHCP.

Methods/design

This mixed methods health services research project will involve implementation and evaluation of the EDMHCP in four exemplar ED-CMHA dyads. The Theoretical Domains Framework will be used to develop a tailored intervention strategy to implement the EDMHCP. A multiple baseline study design and interrupted time-series analysis will be used to determine if the EDMHCP has improved health care utilization, medical management of the MH problems, and health sector coordination. The primary process outcome will be the proportion of patients with MH-specific recommendations documented in the health record. The primary service outcome will be the proportion of patients receiving the EDMHCP-recommended follow-up at 24-h or at 7 days. Data sources will include qualitative interviews, health record audits, administrative databases, and patient surveys. A concurrent process evaluation will be conducted to assess the degree of variability and fidelity in implementation across the sites.

Discussion

This paper presents a novel model for measuring the effects of the EDMHCP. Our development process will identify how the EDMHCP is best implemented among partner organizations to deliver evidence-based risk management of children and youth presenting with MH concerns. More broadly, it will contribute to the body of evidence supporting clinical pathway implementation within novel partnerships.

Trial registration

ClinicalTrials.gov (NCT02590302)

Discovery of blood transcriptomic markers for depression in animal models and pilot validation in subjects with early-onset major depression

Early-onset major depressive disorder (MDD) is a serious and prevalent psychiatric illness in adolescents and young adults. Current treatments are not optimally effective. Biological markers of early-onset MDD could increase diagnostic specificity, but no such biomarker exists. Our innovative approach to biomarker discovery for early-onset MDD combined results from genome-wide transcriptomic profiles in the blood of two animal models of depression, representing the genetic and the environmental, stress-related, etiology of MDD. We carried out unbiased analyses of this combined set of 26 candidate blood transcriptomic markers in a sample of 15-19-year-old subjects with MDD (N=14) and subjects with no disorder (ND, N=14). A panel of 11 blood markers differentiated participants with early-onset MDD from the ND group. Additionally, a separate but partially overlapping panel of 18 transcripts distinguished subjects with MDD with or without comorbid anxiety. Four transcripts, discovered from the chronic stress animal model, correlated with maltreatment scores in youths. These pilot data suggest that our approach can lead to clinically valid diagnostic panels of blood transcripts for early-onset MDD, which could reduce diagnostic heterogeneity in this population and has the potential to advance individualized treatment strategies.

Interrupted time-series analysis and its application to behavioral data

This paper uses a question-and-answer format to present the technical aspects of interrupted time-series analysis (ITSA). Topics include the potential relevance of ITSA to behavioral researchers, serial dependency, time-series models, tests of significance, and sources of ITSA information.

A cautionary note on the use of probability values to evaluate interobserver agreement

Proposed methods of assessing the statistical significance of interobserver agreements provide erroneous probability values when conducted on serially correlated data. Investigators who wish to evaluate interobserver agreements by means of statistical significance can do so by limiting the analysis to every k(th) interval of data, or by using Markovian techniques which accommodate serial correlations.

Primary care clinicians' use of standardized psychiatric diagnoses

OBJECTIVE

Treatment of child mental health (MH) problems should be informed by psychiatric diagnosis. Whether primary care clinicians (PCCs) use standardized psychiatric diagnostic criteria to direct the treatment of child MH problems is unknown. This study investigated PCCs' use of Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria during office visits.

METHODS

The data were obtained from 3674 children ages 4-15 years who were recognized as having one or more MH problems during office visits by clinicians participating in the Child Behaviour Study. Parents completed questionnaires before seeing the clinician. Clinicians completed a survey after the visit. The primary outcome was whether PCCs used standardized criteria to generate a diagnosis for children with recognized MH problems.

RESULTS

Clinicians used DSM criteria in 23% of visits in which a psychosocial problem was recognized, and 57% of PCCs reported no use of DSM. DSM criteria were used most frequently (38% of visits) when PCCs reported attention problems. Medications were much more likely to be prescribed during visits when PCCs diagnosed using DSM criteria (63% of visits vs. 19% when criteria were not used). However, only 51% of psychotropic medication prescriptions were based on a DSM diagnosis.

CONCLUSIONS

Clinicians used standardized criteria infrequently, and primarily to diagnose attention problems.

Decreased cortisol levels in adolescent girls with conduct disorder

BACKGROUND

Female adolescent antisocial behavior is increasing, but little is known about the neuroendocrinologic aspects of this disorder. On the basis of reports of decreased cortisol levels in antisocial males, we investigated morning plasma cortisol levels in adolescent girls with conduct disorder (CD).

METHODS

Three plasma samples for cortisol levels were taken every 20 minutes between 8 and 9 AM in 47 adolescent girls with CD (mean +/- SD age, 16.5 +/- 0.9 years) and 37 normal control girls (mean age, 16.0 +/- 0.8 years). All blood was drawn within 72 hours after the onset of menstrual flow.

RESULTS

Girls with CD had significantly lower cortisol levels than girls in the normal control group at all 3 sampling times. This finding was not due to procedural factors, demographic characteristics, or the use of medications. The girls with CD who had no other psychiatric problems had lower cortisol levels than girls with other disorders or those in the normal control group. In the multiple regression analysis, having CD predicted 10% of the variance in cortisol levels.

CONCLUSIONS

Morning plasma cortisol levels were significantly diminished in adolescent girls with CD. Decreased cortisol levels appear to be most strongly associated with antisocial girls who do not have other psychiatric disorders.

Physician gender and psychosocial care for children: attitudes, practice characteristics, identification, and treatment

OBJECTIVE

To examine differences by physician gender in the identification and treatment of childhood psychosocial problems.

DESIGN

Survey of patients (n = 19,963) and physicians (n = 366) in primary care offices in 2 large, practice-based research networks. Multivariate regressions were used to control for patient, physician, and visit characteristics, with a correction for the clustered sample.

SUBJECTS

Children ages 4 to 15 years seen consecutively for nonemergent care.

MEASURES

Physician report of attitudes, training, practice factors, and identification and treatment of psychosocial problems. Parental report of demographics and behavioral symptoms.

RESULTS

Compared with male physicians, female physicians were less likely to view care for psychosocial problems as burdensome. They were more likely to see children who were female, younger, black or Hispanic, in single-parent households, enrolled in public or managed health plans, and with physical health limitations. Children seen by male physicians had higher symptom counts. Male physicians were more likely to report having primary care responsibility for their patient and that parents agree with their care plan. Female physicians spent more time with patients. After controlling for these differences, female physicians did not differ from male physicians in identification or treatment of childhood psychosocial problems.

CONCLUSIONS

Male and female physicians see different kinds of children for different visit purposes and have different kinds of relationships with their patients. After controlling for these factors, management of childhood psychosocial problems does not differ by physician gender. Improving management of psychosocial conditions depends on identifying modifiable factors that affect diagnosis and treatment; our work suggests that characteristics of the practice environment, physician-patient relationship, and patient self-selection deserve more research.

Does the family APGAR effectively measure family functioning?

BACKGROUND

The Family APGAR has been widely used to study the relationship of family function and health problems in family practice offices.

METHODS

Data were collected from 401 pediatricians and family physicians from the Pediatric Research in Office Settings network and the Ambulatory Sentinel Practice Network. The physicians enrolled 22,059 consecutive office visits by children aged 4 to 15 years. Parents completed a survey that included the Family APGAR and the Pediatric Symptom Checklist. Clinicians completed a survey that described child psychosocial problems, treatments initiated or continued, and specialty care referrals.

RESULTS

Family dysfunction on the index visit often differed from dysfunction at follow-up (kappa=0.24). Only 31% of the families with positive Family APGAR scores at baseline were positive at follow-up, and only 43% of those with positive scores at follow-up had a positive score at the initial visit. There were many disagreements between the Family APGAR and the clinician. The Family APGAR was negative for 73% of clinician-identified dysfunctional families, and clinicians did not identify dysfunction for 83% of Family APGAR-identified dysfunctions (kappa=0.06).

CONCLUSIONS

Our data do not support the use of the Family APGAR as a measure of family dysfunction in the primary care setting. Future research should clarify what it does measure.

Primary care treatment of pediatric psychosocial problems: A study from pediatric research in office settings and ambulatory sentinel practice network

OBJECTIVE

Psychosocial problems cause much of the morbidity among children, and their frequency of presentation in primary care is growing. How is primary care treatment of children's psychosocial problems affected by child symptoms, physician training, practice structure, insurance, physician/patient relationship, and family demographics?

DESIGN

Questionnaire study of treatment of psychosocial problems during office visits by children.

SETTINGS

At total of 401 primary care offices from 44 US states, Puerto Rico, and Canada.

PATIENTS

From 21 150 children seen in office visits, we selected children with an identified psychosocial problem but who were not already receiving specialty mental health services (n = 2618 children).

OUTCOME MEASURES

Clinicians' decisions to counsel families, to refer children to mental health specialists, or to prescribe medication.

RESULTS

The treatment choices of primary care clinicians (PCCs) were generally independent of patients' demographics or insurance status. Clinicians' training, beliefs about mental health, and practice structure had no effect on treatment choices. However, clinicians seeing their own patients were more likely to prescribe medications for attention problems. The clinician's perception about whether the parent agreed with the treatment choice was important for every treatment modality. Counseling and referral were more common and medication was less common when a problem was newly recognized at the visit.

CONCLUSIONS

Structural factors such as practice type, insurance coverage, and physician training were less important for treatment than were process factors, such as whether the visit was a psychosocial problem visit, whether the problem was newly or previously recognized, and whether the family and clinician were familiar with each other and in accord about treatment.

Sources of coercive behaviours in psychiatric admissions

OBJECTIVE

Coercion during psychiatric admissions has been a topic of debate for many years. Although there has been considerable research on patients' perceptions of coercion, there has been no work on who places pressures on patients to be admitted.

METHOD

This article integrates interview data from interviews with patients, admitting staff and family and friends to describe the pressures brought to bear on patients to be admitted.

RESULTS

Health-care professionals appear to be the most important source of pressures on patients, and to have the most impact on patients' perceptions of coercion. However, there are differences in type of pressure, and the pressures used by family and friends appear to have the most longstanding impact.

CONCLUSION

Legal and clinical efforts to reduce the level of coercive pressures on patients need to recognize the importance of mental-health professionals, including especially those who are not legally mandated to participate in the admission process.

Patients' revisions of their beliefs about the need for hospitalization

OBJECTIVE

An influential rationale for involuntary hospitalization is that prospective patients who refuse hospitalization at the time it is offered are likely to change their belief about the necessity of hospitalization after receiving hospital treatment. The authors examine how patients changed their evaluations of psychiatric hospitalization following hospital treatment.

METHOD

The authors studied 433 patients who were interviewed about their hospitalization within 2 days of their admission to a psychiatric hospital; 267 of these patients were reinterviewed 4-8 weeks following discharge.

RESULTS

When reinterviewed at follow-up, 33 (52%) of 64 patients who said at admission that they did not need hospitalization said that, in retrospect, they believed they had needed it. Only 9 (5%) of 198 patients who said at admission that they needed hospitalization shifted to saying that they had not needed it.

CONCLUSIONS

Many of the patients who initially judged that they did not need hospitalization revised their belief after hospital discharge and reported that they had needed hospital treatment. However, perceptions of coercion were stable from admission to follow-up, and patients' attitudes toward hospitalization did not become more positive. Coerced patients did not appear to be grateful for the experience of hospitalization, even if they later concluded that they had needed it.

Prospective study of displaced children's symptoms in wartime Bosnia

BACKGROUND

This study examines the psychological symptoms of Bosnian children exposed to war and trauma, and detects changes in these symptoms over time.

METHOD

A total of 147 displaced children residing in refugee centers in Bosnia completed self-report assessments of anxiety, depressive, and posttraumatic stress symptoms at two time points.

RESULTS

Symptoms of posttraumatic stress, anxiety, and depression showed a greater decrease in boys relative to girls over time.

CONCLUSION

Gender may be an important factor in the natural course of trauma-related symptoms among war traumatized children. Further research is needed to better understand the psychological effects of war trauma on children, and the natural course of posttraumatic symptoms, so as to improve interventions targeted to this vulnerable population.

A 5-year comparison of hydroxyapatite-coated titanium plasma-sprayed and titanium plasma-sprayed cylinder dental implants

OBJECTIVE

A preliminary report from this study showed that hydroxyapatite-coated (HA) titanium plasma-sprayed (TPS) cylinder implants had fewer failures than TPS cylinder implants before prosthetic loading. The purpose of this article is to report the long-term success associated with the 2 systems. In addition, local and systemic factors that may influence the success or failure of the implants were analyzed.

STUDY DESIGN

Each of 65 subjects was randomized to either HA-coated TPS or TPS cylinder implants. Loss of an implant was considered a failure. Failures were analyzed in terms of the coating of the implant, age and gender of the patient, location and length of the implant, opposing dentition, and smoking status. Data were statistically analyzed through use of chi-square tests.

RESULTS

Of 351 implants that were placed, 13 were lost before prosthetic loading and 17 were lost after prosthetic loading. The overall success rate was 92.8%. Three hundred thirty-eight implants were prosthetically loaded. The implant success rate after prosthetic loading was 95.3%. There was an overall nonsignificant higher failure rate for the TPS implants (8.0%). Patient age and patient gender were nonsignificant variables. Ten-mm implants had a significantly higher failure rate (17.4%; chi-square, 1.00; P = .39). Before prosthetic loading, more implants failed in the posterior mandible; after prosthetic loading, more implants failed in the anterior maxilla (chi-square, 8.97; P = .03). More implants failed when they were opposed by natural dentition or hybrids (chi-square, 7.36; P = .007). Smoking history was a significant factor (chi-square, 5.2; P = .002).

CONCLUSIONS

Statistically, there is little difference between the 2 systems. Local and systemic factors appear to play a greater role in implant failure than does the surface of the implant.

Factual sources of psychiatric patients' perceptions of coercion in the hospital admission process

OBJECTIVE

The purpose of this study was to determine what predicts patients' perceptions of coercion surrounding admission to a psychiatric hospital.

METHOD

For 171 cases, the authors integrated data from interviews with patients, admitting clinicians, and other individuals involved in the patients' psychiatric admissions with data from the medical records. Using a structured set of procedures, coders determined whether or not nine coercion-related behaviors occurred around the time of admission. Correlation and regression analyses were used to describe the predictors of patients' scores on the MacArthur Perceived Coercion Scale.

RESULTS

The use of legal force, being given orders, threats, and "a show of force" were all strongly correlated with perceived coercion. A least squares regression accounted for 43.3% of the variance in perceived coercion. The evidence also suggested that force is typically only used in conjunction with less coercive pressures.

CONCLUSIONS

Force and negative symbolic pressures, such as threats and giving orders about admission decisions, induce perceptions of coercion in persons with mental illness. Positive symbolic pressures, such as persuasion, do not induce perceptions of coercion. Such positive pressures should be tried in order to encourage admission before force or negative pressures are used.

Dying enterocytes downregulate signaling pathways converging on Ras: rescue by protease inhibition

Organ and cell cultures of the small intestine serve as excellent in vitro models for programmed cell death (PCD). Cells cultured in serum-free, minimal medium rapidly died, as evidenced by histological changes, internucleosomal DNA cleavage, and TdT-mediated dUTP nick end labeling. Cell death was pervasive, although nonepithelial cells within the fibrovascular villus core were spared. PCD did not require a functional p53 gene. Serine and cysteine protease inhibitors, but not FCS, suppressed it. Relative to structural and functional proteins, dying enterocytes rapidly downregulated Ras-convergent proteins, including epidermal growth factor receptor, Erb-B2, and the son of sevenless guanine nucleotide exchangers. Reductions in the steady-state levels of both protein and mRNA were observed. These reductions were prevented by a combination of death-defying serine and caspase inhibitors, indicating a requirement for the initiation of death. Thus, during catastrophic PCD, intestinal epithelial cells delete cell surface signaling pathways responsible for Ras activation.

Circadian regulation of CREB transcription factor in mouse esophagus

Very little is known about the circadian regulation of cell entry into the S and M phases of the cell cycle. Yet, in the mouse esophagus, a seven- to ninefold increase in DNA synthesis coincides with nocturnal feeding. The phosphorylation of the cAMP response element binding protein (CREB), a transcriptional factor, may regulate hypothalamic circadian rhythms in the brain. Here, we investigate the circadian regulation of CREB and Ser-133-phospho-CREB (PCREB) in the mouse esophagus by immunocytochemical and biochemical methods. We found that, during the dark phase, coincident with the onset of feeding and increased DNA synthesis, esophageal CREB and PCREB expression decreased. Although CREB-like immunoreactivity (CREB-lir) was expressed in many different cell types, it was concentrated in the mucosa, particularly in the replicating basal cell layer. The injection of epidermal growth factor, at a dosage known to maximally stimulate esophageal DNA synthesis in a 4- to 8-h period, rapidly decreased PCREB levels within 10 min of injection. We speculate that PCREB-lir may be involved in the circadian regulation of cell cycle events in the intact mouse esophagus.

The family APGAR and psychosocial problems in children: a report from ASPN and PROS

BACKGROUND

Our study examined whether the lack of social support as measured by the Family APGAR was related to parents' and physicians' identification of child psychosocial problems and sociodemographic and symptom characteristics of the children screened.

METHODS

The parents of 9626 children, ages 4 to 15 years, seen for outpatient medical visits participated in this national study. Parents completed the Family APGAR and the Pediatric Symptom Checklist (PSC), a measure of psychosocial dysfunction. Physicians rated the presence of a new or recurrent psychosocial problem in the child.

RESULTS

Children from families with a lack of social support were 4.3 times as likely to receive scores indicating impairment on the PSC and 2.2 times as likely to be identified as having psychosocial problems by physician report. Families with low social support were significantly more likely to report low parental educational achievement, single parent status, and a history of mental health services for the child. Fifty percent of children from families with low social support were identified as having a psychosocial problem by either the PSC or physician rating, or both; however, only 21% of the children identified with psychosocial impairment by these two measures had scores indicating poor family functioning on the Family APGAR.

CONCLUSIONS

A lack of family social support is associated with child psychosocial dysfunction as assessed by two different measures. However, the Family APGAR was not a sensitive measure of child psychosocial problems, and thus it supplements, but does not replace, information concerning the child's overall psychosocial functioning.

A euryarchaeal lysyl-tRNA synthetase: resemblance to class I synthetases

The sequencing of euryarchaeal genomes has suggested that the essential protein lysyl-transfer RNA (tRNA) synthetase (LysRS) is absent from such organisms. However, a single 62-kilodalton protein with canonical LysRS activity was purified from Methanococcus maripaludis, and the gene that encodes this protein was cloned. The predicted amino acid sequence of M. maripaludis LysRS is similar to open reading frames of unassigned function in both Methanobacterium thermoautotrophicum and Methanococcus jannaschii but is unrelated to canonical LysRS proteins reported in eubacteria, eukaryotes, and the crenarchaeote Sulfolobus solfataricus. The presence of amino acid motifs characteristic of the Rossmann dinucleotide-binding domain identifies M. maripaludis LysRS as a class I aminoacyl-tRNA synthetase, in contrast to the known examples of this enzyme, which are class II synthetases. These data question the concept that the classification of aminoacyl-tRNA synthetases does not vary throughout living systems.

The validity of mental patients' accounts of coercion-related behaviors in the hospital admission process

Although the recent development of a measure for perceived coercion has led to great progress in research on coercion in psychiatric settings, there still exists no consensus on how to measure the existence of real coercive events or pressures. This article reports the development of a system for integrating chart review data and data from interviews with multiple participants in the decision for an individual to be admitted to a psychiatric hospital. The method generates a "most plausible factual account" (MPFA). We then compare this account with that of patients, admitting clinicians and other collateral informants in 171 cases. Patient accounts most closely approximate the MPFA on all but one of nine dimensions related to coercion. This may be due to wider knowledge of the events surrounding the admission.

Clinical versus actuarial predictions of violence of patients with mental illnesses

This study compared the accuracy of an actuarial procedure for the prediction of community violence by patients with mental illness with the accuracy of clinicians' ratings of concern about patients' violence. Data came from a study in which patients were followed in the community for 6 months after having been seen in a psychiatric emergency room. Accuracy of actuarial prediction was estimated retrospectively, with a statistical correction for capitalization on chance. Actuarial prediction had lower rates of false-positive and false-negative errors than clinical prediction. The seriousness of the violence correctly identified by the actuarial predictor (the true positives) was similar to the seriousness identified by clinicians. Actuarial predictions based only on patients' histories of violence were more accurate than clinical predictions, as were actuarial predictions that did not use information about histories.

Clinical versus actuarial predictions of violence of patients with mental illnesses

This study compared the accuracy of an actuarial procedure for the prediction of community violence by patients with mental illness with the accuracy of clinicians' ratings of concern about patients' violence. Data came from a study in which patients were followed in the community for 6 months after having been seen in a psychiatric emergency room. Accuracy of actuarial prediction was estimated retrospectively, with a statistical correction for capitalization on chance. Actuarial prediction had lower rates of false-positive and false-negative errors than clinical prediction. The seriousness of the violence correctly identified by the actuarial predictor (the true positives) was similar to the seriousness identified by clinicians. Actuarial predictions based only on patients' histories of violence were more accurate than clinical predictions, as were actuarial predictions that did not use information about histories.

Perceived coercion in mental hospital admission. Pressures and process

BACKGROUND

Patients' perceptions of coercion in admission may affect their attitude toward subsequent treatment, including their inclination to adhere to treatment plans. This study looks at the determinants of patients' perceptions of coercion.

METHODS

A sample of 157 patients admitted to a rural Virginia state hospital and a Pennsylvania community hospital were interviewed within 48 hours of admission about their experience of coming to the hospital. All subjects were 17 years or older. Diagnoses were diverse, and 42% were involuntarily committed. The interview gathered an open-ended description of the admission experience followed by a structured interview that included several measures.

RESULTS

Perceptions of being respectfully included in a fair decision-making process ("procedural justice") and legal status were most closely associated with perceived coercion, and a significant relationship was found with perceived negative pressures, ie, force and threats. However, only procedural justice was related to the perception of coercion at both sites and with both voluntary and involuntary patients.

CONCLUSIONS

Patients' feelings of being coerced concerning admission appears to be closely related to their sense of procedural justice. It may be that clinicians can minimize the experience of coercion even among those legally committed by attending more closely to procedural justice issues.

Regression analyses of counts and rates: Poisson, overdispersed Poisson, and negative binomial models

The regression models appropriate for counted data have seen little use in psychology. This article describes problems that occur when ordinary linear regression is used to analyze count data and presents 3 alternative regression models. The simplest, the Poisson regression model, is likely to be misleading unless restrictive assumptions are met because individual counts are usually more variable ("overdispersed") than is implied by the model. This model can be modified in 2 ways to accomodate this problem. In the overdispersed model, a factor can be estimated that corrects the regression model's inferential statistics. In the second alternative, the negative binomial regression model, a random term reflecting unexplained between-subject differences is included in the regression model. The authors compare the advantages of these approaches.

Can human genetic enhancement be prohibited?

This article seeks to reframe the ethical discussion of genetic enhancement, which is the use of genetic engineering to supply a characteristic that a parent might want in a child that does not involve the treatment or prevention of disease. I consider whether it is likely that enhancement can be successfully prohibited. If genetic enhancement is feasible, it is likely that there will be demand for it because parents compete to produce able children and nations compete to accumulate human capital in skilled workers. If some parents or nations begin using genetic enhancement, this will change these competitions in ways that increase the incentives for others to use it. Therefore, a ban on genetic enhancement would be unstable, because once the ban was breached by defectors the motivation of others to uphold it would weaken, making the ban liable to collapse. The argument provides a new perspective on slippery slopes to dangerous technology.

Measurement of end-tidal PCO2 and PO2

This article describes the basic principles of the measurement of end-tidal carbon dioxide (CO2) and oxygen (O2) in humans. The description includes definitions of the major parameters of breathing (e.g., the composition of atmospheric air, arterial and venous blood; metabolism; lung capacity; volumetric measures of tidal volume, minute volume, and respiration frequency; pH regulation and cerebral acidity; barometric pressure and the partial pressures of CO2 and O2), the basic anatomical features of breathing, the means by which gases are exchanged between the lungs and blood, the techniques used in the measurement of respiratory variables, and the interpretation of these measurements.

Hierarchical continuous-time sequential analysis: a strategy for clinical research

This article presents a strategy for analyzing interdyadic differences in sequential data on social interactions. The social interactive data could be, for example, a nonverbal behavior such as eye gazes within dyads, with measurement of both the sequence of behaviors and their durations. This article shows (a) how one can statistically describe an interactional structure within each dyad governing the stream of that dyad's social interactive behavior and (b) how scores describing dyadic structures can be related to covariate information about the dyads. The covariates could include, for example, ratings of therapist skill or client psychopathology. Methods for relating measures of within-dyad structures in interactive behavior to between-dyad covariates could be a powerful tool for research on psychotherapy process or interpersonal relationships.

Hierarchical continuous-time sequential analysis: a strategy for clinical research

This article presents a strategy for analyzing interdyadic differences in sequential data on social interactions. The social interactive data could be, for example, a nonverbal behavior such as eye gazes within dyads, with measurement of both the sequence of behaviors and their durations. This article shows (a) how one can statistically describe an interactional structure within each dyad governing the stream of that dyad's social interactive behavior and (b) how scores describing dyadic structures can be related to covariate information about the dyads. The covariates could include, for example, ratings of therapist skill or client psychopathology. Methods for relating measures of within-dyad structures in interactive behavior to between-dyad covariates could be a powerful tool for research on psychotherapy process or interpersonal relationships.

Political intervention in scientific peer review. Research on adolescent sexual behavior

In 1991, the Secretary of Health and Human Services (HHS) rescinded funding for a survey of adolescent health risk-taking behavior. The decision overturned a series of scientific and ethical peer and administrative reviews of the research, which had been chosen in a competitive evaluation of proposals to advance knowledge about the prevention of acquired immunodeficiency syndrome (AIDS) and other diseases. The cancellation, coupled with congressional action to block similar research, left a gap in scientific data about adolescent health risk-taking. The cancellation may also encourage the further use of political criteria in evaluating proposals for scientific research. Procedures for funding scientific research should be reformed to protect peer review from arbitrary political intervention. Through a discussion of this decision and its consequences for AIDS prevention research, principles that justify autonomous peer review are clarified and a reform that could strengthen it is discussed.

Political intervention in scientific peer review. Research on adolescent sexual behavior

In 1991, the Secretary of Health and Human Services (HHS) rescinded funding for a survey of adolescent health risk-taking behavior. The decision overturned a series of scientific and ethical peer and administrative reviews of the research, which had been chosen in a competitive evaluation of proposals to advance knowledge about the prevention of acquired immunodeficiency syndrome (AIDS) and other diseases. The cancellation, coupled with congressional action to block similar research, left a gap in scientific data about adolescent health risk-taking. The cancellation may also encourage the further use of political criteria in evaluating proposals for scientific research. Procedures for funding scientific research should be reformed to protect peer review from arbitrary political intervention. Through a discussion of this decision and its consequences for AIDS prevention research, principles that justify autonomous peer review are clarified and a reform that could strengthen it is discussed.

The accuracy of predictions of violence to others

OBJECTIVE

To assess the accuracy of clinicians in predicting violence in mental patients. Specifically, to determine if clinicians can predict violence when variation in rates of violence attributable to age, race, and sex is controlled.

DESIGN

Two samples of psychiatric patients, matched on age, race, sex, and admission status, were followed up in the community during a 6-month period. One group included individuals assessed by psychiatric emergency department clinicians as likely to be violent to another person during the follow-up period; the other was a comparison group. Patients provided self-reports of violent incidents, and a "collateral," ie, an individual with detailed knowledge of the patient's life, provided this same information. Official records were also reviewed.

SETTING

Patients were recruited in the emergency department of a metropolitan psychiatric hospital. Patients and collaterals were interviewed in their homes or in public places in the community.

PATIENTS OR OTHER PARTICIPANTS

A consecutive sample of individuals coming into a psychiatric emergency department during daylight and evening shifts was obtained. A total of 2452 patients were approached for consent and 1948 consented. A final sample of 357 patients whom clinicians assessed as likely to be violent and their matched comparison patients were included.

MAIN OUTCOME MEASURES

Patients', collaterals', and official records' reports of incidents in which the patient laid hands on another person or threatened someone with a weapon.

RESULTS

Violence during the follow-up period was reported in approximately 45% of the cases: 36% in the comparison group and 53% in the cases predicted to be violent. Overall clinical accuracy was significantly better than chance, but predictions of female patients' violence were not better than chance.

CONCLUSIONS

The level of patient violence reported using self-reports and collateral reports was higher than has been obtained using other methods. Clinical judgment adds to predictive accuracy, but overall accuracy was modest and particularly low for female patients.

Inclusion, motivation, and good faith: the morality of coercion in mental hospital admission

We administered a semi-structured interview to 157 patients shortly after their admission to a psychiatric hospital. In the first, and open-ended, part of the interview, patients were asked to talk about what had been going on in their lives that led to their coming into the hospital. Then, in a more structured format, they were asked more specific details about who was involved, the patients' relationships with those involved, whether any attempts were made to influence the patient to come into the hospital, and whether such attempts were perceived as fair by the patient. This article presents a qualitative review of the transcripts of a subset of these interviews. It attends specifically to patients' perceptions of the morality of attempts by others--primarily family members, friends and mental health professionals--to influence them to be admitted to the hospital, and of the morality of the process by which these influence attempts resulted in admission.

Two scales for measuring patients' perceptions for coercion during mental hospital admission

Legal and extra-legal coercion are pervasive in mental hospital admission and there are sharp disputes about its appropriate role. This article presents two scales for measuring psychiatric patients' perceptions of coercion during hospital admission and reports data on these scales' internal consistency. We measure patients' perceptions of coercion by asking questions, in either an interview or questionnaire format, about their experience of lack of control, choice, influence, and freedom in hospital admission. Patients' responses to questions about their perceptions of coercion were highly internally consistent. The internal consistency of the scale was robust with respect to variation in site, instrument format, patient population, and interview procedure. Correspondence analysis was used to construct two numerical scales of perceived coercion.