The Canadian Journal of Psychiatry

To review the implications of current research on clinical practice.

An examination of the literature over the last 10 years and the data from our own study group.

A synopsis of current psychobiological and psychological conceptual underpinnings of the nature and process of cravings and relapses among substance-dependent individuals is presented. The biopsychosocial dimensions of the clinical assessment of craving components, relapse patterns, and predictors, including relevant instruments, are explored. The panoply of management strategies for cravings and relapses encompasses cue exposure treatment techniques, relapse prevention approaches, anticraving and psychotropic medication, family involvement, and twelve-step programs.

A clinician's familiarity with these strategies should contribute significantly to the transformation of the sense of failure engendered by a patient's relapse into a constructive challenge and opportunity.

To address the theoretical framework behind opioid receptor antagonism for the treatment of nicotine abuse. The current literature is reviewed with a focus on opioid–nicotine interactions in animals and humans. Furthermore, previous studies addressing the effect of opioid antagonism on smoking behaviour are reviewed critically with a focus on suggestions and implications for future trials.

Computerized data bases and reference lists of existing articles were searched for prior publications in 3 areas: 1) the association between nicotine and endogenous opioids, 2) nicotine and reward, and 3) opioid antagonism in the treatment of nicotine use.

Nicotine affects the mesolimbic reward pathway postsynaptically via nicotinic cholinergic receptors and presynaptically via the central nervous system's (CNS) neurohumoral pathways. Thus nicotine results in the release of endogenous opioids that bind to μ receptors, which increases the release of dopamine along this pathway. Studies to date have shown mixed results on the effect of opioid antagonism on smoking behaviour.

The role of opioid antagonism on smoking behaviour is unclear, despite the publication of 5 trials on the subject. Further trials of longer duration should be undertaken and use both longer-acting medications and those more specific to the μ receptor to further focus on the rewarding aspects of nicotine ingestion, thus addressing the craving for this drug. The development of adequate compounds has just begun, and psychiatrists can hope to have a more specific pharmacotherapy to address the cravings and short-term rewards of nicotine use.

To critically review the current literature on pathological gambling as regards the significant psychiatric comorbidities associated with it.

The authors synthesized information found via electronic searches (MEDLINE) and bibliographic-directed searches in over 60 publications.

Pathological gamblers frequently have comorbid substance use disorders. In addition, a subset appear to have comorbid antisocial personality disorder, but they represent a minority when compared with those people who have acquired their antisocial traits as a consequence of their gambling behaviour. A comorbidity with the mood disorders is probable, but methodological concerns and inconsistencies with the data prevent further delineation of this. Emerging research for other disorders possibly associated with pathological gambling is also reviewed.

Pathological gambling is associated with significant psychiatric comorbidity. Recommendations for future research are described.

To provide an accessible source of clinical information related to the diagnosis and treatment of psychiatric morbidity associated with HIV infection.

A selective MEDLINE literature search was used to identify 225 relevant articles, 67 of which were selected for inclusion based upon the presence of psychiatric morbidity. Psychiatric morbidity was defined by the presence of a DSM-IV diagnostic code reflecting psychiatric illness.

HIV-infected patients have high rates of psychiatric morbidity.

The psychiatric evaluation and treatment of psychiatric morbidity improve the quality of life of HIV and AIDS patients.

To determine the prevalence of psychiatric disorders, the degree of psychiatric comorbidity, and the relationship between these and sociodemographic variables in a sample of incarcerated adolescents. A comparison with an age- and sex-matched community sample was conducted.

Age- and sex-matched samples of 49 incarcerated adolescents and 49 nondelinquents were compared for psychiatric morbidity and psychosocial characteristics. Psychiatric diagnoses were determined using the Diagnostic Interview for Children and Adolescents-Revised (DICA-R). Additional information on psychosocial, family, and offence characteristics was obtained using a semistructured interview designed specifically for this study. The prevalence of single and comorbid psychiatric disorders was determined.

Approximately 63.3% of incarcerated adolescents had 2 or more psychiatric disorders. The degree of psychiatric morbidity was directly related to indicators of family adversity, physical abuse, other psychosocial variables, or polysubstance abuse. Psychiatric comorbidity was more frequent in females. Incarcerated adolescents were more likely to endorse symptoms of thought disorder.

Findings identify preventive intervention foci for policy makers and planners in the area of adolescent corrections. Implications for education and training of nonclinical custodial staff are discussed as is the need for a more therapeutic orientation in correctional facilities.

To examine the prevalence and comorbidity of posttraumatic stress disorder (PTSD) in an adolescent inpatient population. A 2-year retrospective chart study was conducted.

Computer-registered data of discharge records from 1993 and 1994 were recovered. Patients were grouped by diagnosis; frequency and chi-square statistical analyses were performed to ascertain the prevalence and the comorbidity of various diagnoses with PTSD.

A total of 187patients, 114 females and 73 males, with a mean age of 15 years were reviewed, and 42% (79) of all patients had a diagnosis of PTSD using DSM-III-R criteria. There were 54 females and 25 males with PTSD; however, gender effect was not clinically significant. Associated comorbidity reaching clinical significance included other anxiety disorders (P = 0.008) and depressive disorders (P = 0.003). Asthma was diagnosed as a significant clinical disorder (P = 0.05) comorbid with PTSD. PTSD diagnoses correlated strongly with a history of abuse (P = 0.0001).

PTSD occurs frequently in adolescent inpatients and is commonly comorbid with other diagnostic presentations. These findings may affect the management of PTSD and prognosis for this population.

Valproic acid, an anticonvulsant medication that enhances GABAergic neurotransmission, has been shown to be helpful in treating behavioural disturbances associated with dementia in several small case series. In an attempt to further document its effectiveness and safety, valproic acid was used to treat a group of elderly patients with dementia and severe agitation.

Sixteen patients, aged 68 to 95 years, who were previously unresponsive to other pharmacotherapeutic interventions, were treated prospectively with open-label divalproex sodium. Effectiveness was measured with the Behave AD (B-AD), the Cohen–Mansfield Agitation Inventory (CMAI), and the Clinical Global Impression Scale (CGIS). Doses ranged from 750 to 2500 mg, divided, per day, with levels of 184 to 742 µmol/L.

Scores on the CMAI declined from 68.8 to 61.0 (P < 0.005), and scores on the B-AD declined from 15.8 to 12.3 (P < 0.004). On the CGIS, 1 patient was rated as very much improved, 3 patients were much improved, 4 patients were minimally improved, and 8 patients were unchanged. The drug was prematurely discontinued in only 1 patient because of side effects.

Valproic acid was shown to be well tolerated with modest effectiveness.

To determine the efficacy of divalproex sodium in the treatment of psychiatric outpatients with treatment refractory panic disorder and comorbid mood instability.

This was an 8-week, open-trial, flexible-dose outcome study conducted at a tertiary care referral centre. Individuals with panic disorder who failed to respond to a cognitive behavioural treatment program and standard antipanic medication, who also suffered from mood instability, were chosen to participate in the study. Divalproex sodium was administered at a flexible dose to reach serum levels of 300 to 600 umol/L (45 to 90 ug/ml) unless limited by tolerance. Patients were rated by self- and rater-administered questionnaires that measured the number of panic attacks, the degree of agoraphobic avoidance, the levels of depression, anxiety, and mood swings, and the perceived sense of well being.

Thirteen subjects were enrolled in the study, and 10 subjects completed it. Two dropped out early because of the medication's side effects, and 1 was lost within the first month of follow-up. All 10 subjects showed significant improvement in depressive and anxiety symptoms and mood instability. There was also a statistically and clinically significant improvement in panic attacks and measures of quality of life.

These findings suggest that divalproex sodium is useful in the treatment of patients with panic disorder and concomitant mood instability, who are refractory to conventional treatment. Double-blind trials will be required to verify these findings.