Background: The frontal lobe of the human brain is integral in regulating behaviour. Behavioural disturbances such as apathy, disinhibition, and dysexecutive function are well-known consequences of frontal lobe pathology, leading to significant impairment. Heavy episodic drinking (HED) and HIV are common conditions that impair the frontal lobe, with disinhibition frequently being seen in people with HED, apathy in HIV positive patients and both HIV and HED leading to executive dysfunction. There is a paucity of research on the interplay between HIV and HED and how this impacts behaviour associated with frontal lobe dysfunction. The Frontal Systems Behaviour Scale (FrSBe) is a questionnaire designed to measure problematic behaviour associated with frontal systems impairment. It has been used in a range of clinical populations. It consists of a total score and three subscale scores, namely apathy (Scale A), disinhibition (Scale D) and executive dysfunction (Scale E). This tool is easy to administer and has the potential to provide clinically useful information that could guide management of patients with these conditions. Aim: As a first step to knowing more about the complex interplay between HIV and HED and its effects on frontal lobe function, the aim of this study was to determine the relationship between HIV status, HED and frontal-systems behavioural dysfunction (impulsivity, apathy, and executive dysfunction) as measured by the FrSBe. Methods: Participants for this quantitative, cross-sectional, and analytical study were recruited from the Nolungile Clinic in Khayelitsha, Cape Town. They were grouped according to their HIV- and HED status. Relevant demographic and clinical data were obtained. Participants completed the Substance Abuse and Mental Illness Symptoms Screener (SAMISS) questionnaires and the FrSBe self-report measure that was translated into isiXhosa. Both measures were scored and the FrSBe raw scores were converted to T-scores. Results: A total of the 99 participants met the inclusion criteria, of which 25 were in the HED only group, 22 in the HIV+ only group, 26 in the dual group, and 26 were in the control group. The mean age (SD) of the sample was 37.92 (8.8) years. There was a statistical difference between groups for the total drinking score on the SAMISS (p = 65), were present on the FrSBe Total Score in 29 of the participants. On the apathy subscale score, 36 participants had clinically significant (T-score >= 65) deficits, 14 had deficits on the disinhibition subscale, and 34 had on the executive dysfunction subscale. There were no statistically significant differences in the proportion of participants with clinically significant deficits between groups for any FrSBe scores. Conclusions: This study shows that people with HED have more dysfunctional behaviour associated with frontal system impairment and are more disinhibited. HIV status does not appear to influence frontal system behaviour. These finding needs to be interpreted with caution as the study FrSBe was administered in isiXhosa, in which it has not been validated, and no normative data was available for the study population. Future studies validating the FrSBe in a South African context and deriving normative data for South African populations would be a first step into developing the FrSBe into a clinically useful tool. This could, in turn, potentially lead to improved care and treatment in these conditions by identifying specific impairments and problematic behaviours as targets for intervention.

Mental disorders are highly prevalent and represent an increasingly important public health priority in Canada and globally. Extensive research suggests that exposure to prenatal maternal stress can negatively impact offspring neurodevelopment and mental health. However, the factors that influence the development of mental disorders are varied, and do not occur in isolation. As a result, ascertaining which variables may drive or influence the associations between prenatal stress and mental disorders in children is particularly important, given the substantial burden that is attributed to poor mental health. The overarching aim of this doctoral thesis is to examine how biological and psychosocial factors influence the relationships between prenatal maternal stress and children’s mental health outcomes. Four longitudinal studies were conducted to address this aim, using data from three international prospective birth cohort studies. Analyses comprised of structural equation modelling techniques, including latent moderated structural equation models and mediation analyses. The first two studies utilized data from a Norwegian birth cohort study to examine how parenting and maternal positive mental health, respectively, modified the associations between prenatal maternal stress and children’s internalizing and externalizing symptoms. Broadly, these results demonstrated that positive influences attenuated the associations between prenatal maternal stress and children’s internalizing and externalizing symptoms, whereas negative influences strengthened the associations. The final two studies utilized data from Dutch and British birth cohorts. These studies sought to examine whether maternal and child inflammatory marker concentrations mediated the associations between prenatal maternal stress and children’s mental health outcomes. There was no significant mediation through maternal levels of C-reactive protein during pregnancy, however, the association between prenatal maternal stress and generalized anxiety disorder in adolescence was mediated by children’s levels of interleukin-6. Prenatal maternal stress was consistently associated with children’s mental health across all four studies. This doctoral thesis has identified several important factors that influence the associations between prenatal maternal stress and children’s mental health. Findings can serve to facilitate further research in this area, and ultimately, impact both health policy and clinical practice by stimulating the provision of tailored prevention and intervention efforts that may potentially reduce the burden of poor mental health.

Background. The National Institutes of Health recently recommended acupuncture as an effective tool for the treatment of various health problems. Acupuncture is an old technique but has been popular in the United States only since 1972. Its history, theories, and indications are not well known to the medical community. Methods. We reviewed the literature to gather information on the history, techniques, physiology, indications, adverse effects, and opposing views to acupuncture. Results. The mechanism by which acupuncture works involves neurotransmitters and adrenocorticotropic hormones. It appears to be effective in the treatment of pain, nausea, and drug detoxification and in stroke victims. Studies suggest acupuncture is no more effective than placebo. Acupuncture side effects have rarely been reported. Conclusions. Acupuncture appears to be a safe and effective alternative medical therapy for certain health problems. More controlled research is necessary to better understand the range of its clinical application.

Over the last 11 years, I have had the privilege of being welcomed into the tnlllsgender community in spite of my status as a psychiatrist. I say in spite 0(, not because of, largely as a result of the grave in justices many transgendered persons have suffered at the hands of some of my ill -informed and, at times, harshly judgmental colleagues. I' m disheartened to say that most of these self-identified patients would have been better served if they had been referred to someone with appropriate knowledge and training in this highly specialized area of human behavior. It was clear from my very first fo ray into the transgender community (the ~CrossPort" support group in Cincinnati, Ohio, in 1985) that cross-dressing men and their spouses (I wi!! use the shorthand notat ion "spouse" for a ll women in emotionally committed relationships with a transgendered man) were hungry for knowledge and for legit imate, open-minded inquiry into the phenomenon of cross-dressing. What they usually found when they went to a library was anything but open-minded and was often wrinen by "researchers" who had never spent so much as one evening with a support group anywhere in the country, in spite of the facr that hundreds exist (sec Appendix I for a listing of sources for information and support). Papers were written fro m the perspective of a treating health-care professional sitting behind a desk talking to a self-identified patient. Information was then generalized to the population of cross-dressers and their spouses at large, even though the majority of such individuals never seek psychiatric assistance or identify themselves as patients (Brown, 1995).

Physicians are not immune to psychosocial problems but may face unique impediments to attending to them. Self-care among physicians is not a topic generally included as a part of professional training, nor is it a topic that readily receives consideration in professional practice. The stresses of professional practice can exact a great toll, however, and self-neglect can lead to tragic consequences. In some areas, particularly suicide rates, physicians have increased vulnerability, and in other areas problems may be unrecognized (depression, substance abuse, marital problems, and other stress-related concerns). Female physicians show some particular areas of risk. In this paper, we raise questions about how and why physicians may be particularly vulnerable, review the available literature about the extent and nature of such problems in physicians, discuss possible factors related to the development of these problems in physicians, and suggest a variety of solutions to improve physician self-care.

Over the last 11 years, I have had the privilege of being welcomed into the tnlllsgender community in spite of my status as a psychiatrist. I say in spite 0(, not because of, largely as a result of the grave in justices many transgendered persons have suffered at the hands of some of my ill -informed and, at times, harshly judgmental colleagues. I' m disheartened to say that most of these self-identified patients would have been better served if they had been referred to someone with appropriate knowledge and training in this highly specialized area of human behavior. It was clear from my very first fo ray into the transgender community (the ~CrossPort" support group in Cincinnati, Ohio, in 1985) that cross-dressing men and their spouses (I wi!! use the shorthand notat ion "spouse" for a ll women in emotionally committed relationships with a transgendered man) were hungry for knowledge and for legit imate, open-minded inquiry into the phenomenon of cross-dressing. What they usually found when they went to a library was anything but open-minded and was often wrinen by "researchers" who had never spent so much as one evening with a support group anywhere in the country, in spite of the facr that hundreds exist (sec Appendix I for a listing of sources for information and support). Papers were written fro m the perspective of a treating health-care professional sitting behind a desk talking to a self-identified patient. Information was then generalized to the population of cross-dressers and their spouses at large, even though the majority of such individuals never seek psychiatric assistance or identify themselves as patients (Brown, 1995).

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Outcome for bipolar disorder remains suboptimal despite the availability of efficacious treatments. To improve treatment effectiveness in clinical practice, a Veterans Affairs study team created a care model conceptually similar to the lithium clinics of the 1970s but augmented by principles of more recent collaborative care models for chronic medical illnesses. This intervention consists of improving patients' self-management skills through psychoeducation; supporting providers' decision making through simplified practice guidelines; and enhancing access to care, continuity of care, and information flow through the use of a nurse care coordinator. Ih this article, which is part I of a two-part report, the authors summarize the conceptual background and development of the intervention, describe the design of a three-year, 11-site randomized effectiveness trial, and report data describing its successful implementation. Trial design emphasized aspects of effectiveness to support generalizability of the findings and eventual dissemination of the intervention. Part II (see companion article, this issue) reports clinical, functional, and overall cost outcomes of the trial.

Objective: The study addressed whether a collaborative model for chronic care, described in part I (this issue), improves outcome for bipolar disorder. Methods: The intervention was designed to improve outcome by enhancing patient self-management skills with group psychoeducation; providing clinician decision support with simplified practice guidelines; and improving access to care, continuity of care, and information flow via nurse care coordinators. In an effectiveness design veterans with bipolar disorder at 11 Veterans Affairs hospitals were randomly assigned to three years of care in the intervention or continued usual care. Blinded clinical and functional measures were obtained every eight weeks. Intention-to-treat analysis (N=306) with mixed-effects models addressed the hypothesis that improvements would accrue over three years, consistent with social learning theory. Results: The intervention significantly reduced weeks in affective episode, primarily mania. Broad-based improvements were demonstrated in social role function, mental quality of life, and treatment satisfaction. Reductions in mean manic and depressive symptoms were not significant. The intervention was cost-neutral while achieving a net reduction of 6.2 weeks in affective episode. Conclusions: Collaborative chronic care models can improve some long-term clinical outcomes for bipolar disorder. Functional and quality-of-life benefits also were demonstrated, with most benefits accruing in years 2 and 3.