Faculty Bibliography

OBJECTIVE: This study examines the association between discrimination due to race and other attributes (e.g., sex, age) and self-assessed mental and physical health among Latinos and blacks. DATA SOURCE: Latino and black adult participants (n = 873) identified by random digit dialing were interviewed by telephone in four low-income neighborhoods in New York City: the South Bronx, East Harlem, Central Harlem, and Bedford-Stuyvesant. STUDY DESIGN: In this cross-sectional study, generalized estimating equations were used to fit multilevel multivariable models to test the association between discrimination and poor mental and physical health while controlling for socioeconomic status, access to health care, social support, smoking, and the racial and ethnic composition of each neighborhood. PRINCIPAL FINDINGS: Discrimination due to race and discrimination due to other attributes were associated with poor self-assessed mental but not physical health in separate multivariable models. Persons who experienced multiple domains of discrimination had a greater probability of reporting poor mental health than persons who experienced no discrimination. CONCLUSIONS: Discrimination due to race and other attributes was a significant correlate of mental health among Latinos and blacks independent of other accepted determinants of health.

Physicians have a growing array of pharmacotherapies available for the treatment of substance use disorders. These medications are of central importance in the treatment of opioid and nicotine dependence and are of growing importance in the treatment of alcohol and stimulant dependence. Pharmacotherapy alone is rarely sufficient treatment for substance use disorder; appropriate psychosocial treatment or mutual help (eg, 12-step) participation is almost always indicated whether or not pharmacotherapy is used. Specialized facilities, licensing, and training are necessary for the use of some of the pharmacotherapies discussed in this article. The obstetrician gynecologist must determine the scope of his or her own practice in this area (ie, when to treat and when to refer) based on interest, training and experience, and available resources.

Studies of the acoustic startle response and of its inhibition by the presentation of a non-startling preliminary stimulus (prepulse inhibition, PPI) have revealed deficits in PPI in schizophrenic subjects compared to healthy controls. Animal studies indicate that atypical antipsychotics improve PPI deficits induced by NMDA antagonists more consistently than typical antipsychotics. The effect of medication status on PPI in schizophrenia is unresolved in the literature. In the current study the effects on PPI of the atypical antipsychotic olanzapine and the typical antipsychotic haloperidol were compared to the unmedicated state in subjects with schizophrenia. In a between-group design, 11 schizophrenic subjects on olanzapine, 16 subjects on haloperidol, and 14 subjects who were on no medication received acoustic startle testing with PPI determination. ANOVAs revealed no significant differences in startle to pulse alone stimuli, habituation of startle, or PPI between the olanzapine, haloperidol and unmedicated groups. These 41 subjects with schizophrenia were compared to a group of 21 historical healthy controls and found to have reduced PPI. These data do not indicate a preferential effect of olanzapine compared to haloperidol on sensorimotor gating in schizophrenia. The results are consistent with the hypothesis that PPI impairments are relatively stable across treatment conditions

Quantitative electroencephalographic (qEEG) profiles were studied in cocaine dependent patients in response to cocaine cue exposure. Using neurometric analytical methods, the spectral power of each primary bandwidth was computed and topographically mapped. Additional measures of cue-reactivity included cocaine craving, anxiety and related subjective ratings, and physiological measures of skin conductance, skin temperature, heart rate, and plasma cortisol and HVA levels. Twenty-four crack cocaine-dependent subjects were tested for their response to tactile, visual and audio cues related to crack cocaine or neutral items. All measures were analyzed for significant difference by comparing cocaine versus neutral cue conditions. An increase in cocaine craving, anxiety and related subjective ratings, elevated plasma cortisol levels, and a decrease in skin temperature, were induced by cocaine cue exposure. Distinct qEEG profiles were found during the paraphernalia handling and video viewing (eyes-open), and guided imagery (eyes-closed), phases of cocaine cue exposure. During paraphernalia handling and video viewing, there was an increase in beta activity accompanied by a drop in delta power in the frontal cortex, and an increase in beta mean frequency in the occipital cortex. In contrast, during guided imagery there was an increase in theta and delta power in the frontal cortex, and an increase in beta power in the occipital cortex. Correlation analyses revealed that cue-induced anxiety during paraphernalia handling and video viewing was associated with reduced high frequency and enhanced low frequency EEG activity. These findings demonstrated that EEG activation during cue-induced cocaine craving may be topographically mapped and subsequently analyzed for functional relevance

Preliminary research suggests that naloxone (Narcan), a short-acting opiate antagonist, could be provided by prescription or distribution to heroin users to reduce the likelihood of fatality from overdose. We conducted a random postal survey of 1100 prescription-authorized health care providers in New York City to determine willingness to prescribe naloxone to patients at risk of an opiate overdose. Among 363 nurse practitioners, physicians, and physician assistants responding, 33.4% would consider prescribing naloxone, and 29.4% were unsure. This preliminary study suggests that a substantial number of New York City health care providers would prescribe naloxone for opiate overdose prevention.

Accidental drug overdose is a substantial cause of mortality for drug users. Neighborhood-level factors, such as income distribution, may be important determinants of overdose death independent of individual-level factors. We used data from the Office of the Chief Medical Examiner to identify all cases of accidental deaths in New York City (NYC) in 1996 and individual-level covariates. We used 1990 US Census data to calculate the neighborhood-level income distribution. This multi-level case-control study included 725 accidental overdose deaths (cases) and 453 accidental deaths due to other causes (controls) in 59 neighborhoods in NYC. Overdose deaths were more likely in neighborhoods with higher levels of drug use and with more unequal income distribution. In multi-level models, income maldistribution was significantly associated with risk of overdose independent of individual-level variables (age, race, and sex) and neighborhood-level variables (income, drug use, and racial composition). The odds of death due to drug overdose were 1.63-1.88 in neighborhoods in the least equitable decile compared with neighborhoods in the most equitable decile. Disinvestment in social and economic resources in unequal neighborhoods may explain this association. Public health interventions related to overdose risk should pay particular attention to highly unequal neighborhoods.

The presence of a personality disorder (PD) has been associated with certain types of poor treatment outcomes in patients with substance use disorders (SUDs). The purpose of this study was to determine the prevalence of comorbid PDs in psychiatrically hospitalized adults with both non-SUD Axis I disorders and SUDs, and to assess the relationship between Axis II psychopathology and degree of pretreatment addiction severity and treatment outcome. METHOD: One hundred consecutive inpatients admitted to a mixed dual diagnosis inpatient unit were assessed using semistructured interviews for SUDs, non-SUD Axis I disorders, and PDs. Pretreatment severity was assessed using a modified version of the Addiction Severity Index (ASI). Outcome measures were assessed both during hospitalization and at an initial follow-up appointment after discharge. Statistical analyses were performed comparing dually diagnosed patients with and without Axis II psychopathology. RESULTS: A significant number (53%) of the patients met criteria for at least one personality disorder. Of the PDs, Cluster B PDs were the most prevalent, particularly borderline personality disorder (74%) and antisocial personality disorder (66%). Dually diagnosed patients without an Axis II diagnosis had less severe pretreatment severity measures. During hospitalization, patients with Axis II disorders had higher levels of psychopathology on the Brief Symptom Inventory (BSI) subscales of sensitivity and hostility. However, there was no difference in overall degree of global improvement during hospitalization. During follow-up, patients with Axis II disorders were significantly less likely to be compliant in attending their initial follow-up appointment. CONCLUSIONS: Dual diagnosis inpatients with PDs appear to improve as much as patients without PDs during their inpatient hospitalizations; however, they appear to be less likely to be compliant with attending their initial follow-up appointment

RATIONALE: The acoustic startle response is inhibited when the startling stimulus is preceded by a weaker non-startling acoustic stimulus. This phenomenon, termed prepulse inhibition of acoustic startle (PPI), is impaired in schizophrenics compared to normal controls. To date, there is conflicting evidence regarding whether PPI impairments improve with antipsychotic treatment. OBJECTIVES: To examine the effect of medication status on PPI in schizophrenic subjects. METHODS: First, we performed acoustic startle testing on 16 schizophrenic subjects when they were acutely decompensated off medication and later after they were stabilized on antipsychotic treatment. Second, in a between-group design, we tested 21 schizophrenic subjects off medication, 16 subjects on atypical neuroleptics, and 27 subjects on typical neuroleptics. RESULTS: In both the test-retest study and the between-group study, ANOVAs revealed no significant changes in startle to pulse alone stimuli, habituation of startle to pulse alone stimuli, PPI, latency to response onset, or latency to response peak between the treatment conditions. CONCLUSIONS: Our results do not support the hypothesis that impaired sensorimotor gating in schizophrenia improves with antipsychotic treatment. Rather, impaired gating persists despite symptomatic improvement on medication