Search

The National Institute of Mental Health strategic plan for advancing psychiatric neuroscience calls for an acceleration of discovery and the delineation of developmental trajectories for risk and resilience across the lifespan. To attain these objectives, sufficiently powered datasets with broad and deep phenotypic characterization, state-of-the-art neuroimaging, and genetic samples must be generated and made openly available to the scientific community. The enhanced Nathan Kline Institute Rockland Sample (NKI-RS) is a response to this need. NKI-RS is an ongoing, institutionally-centered endeavor aimed at creating a large-scale (N>1000), deeply phenotyped, community-ascertained, lifespan sample (ages 6-85 years old) with advanced neuroimaging and genetics. These data will be publically shared, openly and prospectively (i.e., on a weekly basis). Herein, we describe the conceptual basis of the NKI-RS, including study design, sampling considerations, and steps to synchronize phenotypic and neuroimaging assessment. Additionally, we describe our process for sharing the data with the scientific community while protecting participant confidentiality, maintaining an adequate database, and certifying data integrity. The pilot phase of the NKI-RS, including challenges in recruiting, characterizing, imaging, and sharing data, is discussed while also explaining how this experience informed the final design of the enhanced NKI-RS. It is our hope that familiarity with the conceptual underpinnings of the enhanced NKI-RS will facilitate harmonization with future data collection efforts aimed at advancing psychiatric neuroscience and nosology.

Background: Advance personal planning (APP) involves planning for future periods of incapacity, including making legal decisions and documents. APP ensures that a person's values and preferences are known and respected. This study aimed to examine knowledge of APP, attitudes and confidence towards APP, and participation in APP activities among older people residing in regional and rural areas., Methods: A cross-sectional survey was conducted with people aged over 65 years residing in and around regional towns in New South Wales, Australia. Participants responded to a social media advertisement or information provided through a community organisation. Data was collected via pen and paper survey or an online survey. The survey was developed for the study and included questions about the participant and their experiences with APP. Poisson regression modelling was conducted to explore the relationship between APP participation and APP knowledge, confidence and attitudes as well as the participant characteristics associated with APP participation., Results: Overall, 216 people completed the survey. Most participants had a will (90%) but only a third (32%) had documented an advance care directive. Knowledge of APP was low with only 2.8% of participants correctly answering all 6 knowledge questions. Participants had a positive attitude towards APP and high level of confidence that they could discuss APP issues with important people in their life. Those with increased knowledge, confidence and attitude towards APP were significantly more likely to participate in APP activities. Older age and having private health insurance were significantly associated with engaging in APP activities. Increased frailty and the presence of health conditions were not associated with increased APP participation., Conclusions: There is a need to increase engagement with APP particularly among those who may be considered frail or have chronic health conditions. Increasing knowledge of, confidence and attitudes towards, APP could help to increase engagement in APP activities., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Cameron et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objective: Attention-deficit/hyperactivity disorder (ADHD) diagnosis in college students has been associated with poor academic outcomes and greater neuropsychological and emotional difficulties. The present study sought to determine whether college students who believe they have ADHD report more neuropsychological deficits than non-ADHD peers. Method: College students ( N  = 1,520) completed a confidential online survey designed to explore ADHD beliefs and subjective neuropsychological impairment. MANOVA was used to examine the association between ADHD beliefs and neuropsychological symptoms. LSD post hoc analysis was used to examine pairwise comparisons across groups. Results: College students who believe they have ADHD reported more neuropsychological deficits than those without ADHD and similar levels of neuropsychological impairment as peers with a self-reported diagnosis of ADHD. Conclusion: Results show a statistically and clinically significant relationship between ADHD belief and neuropsychological impairment among college students. These findings highlight the need for qualified ADHD assessment in college students who believe they have ADHD.

Objectives: Carers of people with dementia experience significant physical, emotional, and social burdens. Needs assessment can provide important information to assist services in providing support to carers to reduce these burdens. However, few studies have examined the prevalence of unmet needs experienced by carers of people with dementia using a quantitative instrument. This study aimed to examine the prevalence and type of unmet needs experienced by carers of people with dementia in Australia., Methods: This was a cross-sectional survey of carers providing support to community-dwelling individuals living with dementia. Carers were recruited through geriatric clinics, aged care providers, support services and community organisations. Consenting carers completed a survey including an 80-item study-specific unmet needs instrument for carers (UNI-C) and sociodemographic characteristics. Descriptive statistics were used to identify the most prevalent unmet needs reported by carers., Results: A total of 169 carers (response rate 47%) completed the survey. Most (87%) carers reported at least one unmet need. Carers reported a median of 16.0 (IQR = 24.0; max = 58) out of a possible 80 unmet needs. The most frequently endorsed unmet needs spanned a range of areas including emotional wellbeing, accessing health and aged care services, managing apathy, and finding information., Conclusion: This study highlighted that a large proportion of carers experience unmet needs associated with caring for someone with dementia. Developing and rigorously testing interventions to meet carers' commonly reported unmet needs are warranted., Supplemental data for this article is available online at https://doi.org/10.1080/13607863.2022.2053833 .

The Queensland fruit fly, Bactrocera tryoni, is a major pest of Australian horticulture which has expanded its range in association with the spread of horticulture over the last ~ 150 years. Its distribution in northern Australia overlaps that of another fruit fly pest to which some authors accord full species status, Bactrocera aquilonis. We have used reduced representation genome-wide sequencing to genotype 359 individuals taken from 35 populations from across the current range of the two taxa, plus a further 73 individuals from six of those populations collected 15-22 years earlier. We find significant population differentiation along an east-west transect across northern Australia which likely reflects limited but bidirectional gene flow between the two taxa. The southward expansion of B. tryoni has led to relatively little genetic differentiation, and most of it is associated with a move into previously marginal inland habitats. Two disjunct populations elsewhere in Australia and three on Melanesian islands are each clearly differentiated from all others, with data strongly supporting establishment from relatively few founders and significant isolation subsequently. Resequencing of historical samples from one of the disjunct Australian populations shows that its genetic profile has changed little over a 15-year period, while the Melanesian data suggest a succession of 'island hopping' events with progressive reductions in genetic diversity. We discuss our results in relation to the control of B. tryoni and as a model for understanding the genetics of invasion and hybridisation processes.

Introduction: Fibromyalgia is a chronic health condition characterized by widespread, severe musculoskeletal pain that affects an estimated 5-7% of the global population. Due to the highly comorbid nature of fibromyalgia, patients with the disorder often respond poorly to traditional pain treatments. Recent studies suggest that patient response may be more favorable to alternative analgesics, such as cannabis. However, the therapeutic potential of cannabis-based pain treatment for fibromyalgia remains unclear. The present study examined the most recent cannabis literature (2015-2019) and provides a critical review of current research on the safety and efficacy of medical cannabis treatments for fibromyalgia., Methods: We followed Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines in searching the PubMed and Medline databases using the search terms "cannabis + fibromyalgia" and then "cannabinoids + fibromyalgia." Inclusion criteria were a) English language, b) published in peer review journals, c) published from 2015 to 2019, d) all study designs except for systematic reviews and meta-analyses, and e) all cannabis preparations., Results: The search identified five applicable studies involving 827 participants that used six different treatments. Review suggested several methodological problems pertaining to generalizability and validity., Conclusion: Although the critically reviewed studies superficially suggest that medical cannabis is a safe and effective treatment for fibromyalgia pain, serious methodological limitations prevent a definitive conclusion regarding the use of cannabinoids for pain management in fibromyalgia patients at this time.

Problem: Given the influence of diet on infant and maternal health outcomes, adequate knowledge about nutrition during pregnancy is critical., Aims: To examine among women receiving antenatal care the proportion who: (1) believe information about diet should be provided as part of routine antenatal care; (2) recall receiving advice about diet as part of care including: (a) when information was provided, (b) the healthcare provider who gave information, and (c) the format in which it was provided; and (3) attitudes towards information received., Methods: A cross-sectional survey was conducted with women attending a public antenatal clinic in New South Wales, Australia. Women were eligible to participate if they were: pregnant or had given birth in the previous 10 weeks; ≥18 years; and had at least one prior antenatal appointment for their current pregnancy., Findings: A total of 223 women (64% consent rate) participated. While the majority (86%) believed healthcare providers should be giving dietary information to pregnant women, only 63% recalled receiving information during their current pregnancy. Most often it was given by a midwife (76%). Information was initially provided in the first (52%) or second (38%) trimester, in both written and verbal form (60%). Approximately one third of participants felt overwhelmed or confused by which foods should be avoided during pregnancy., Conclusions: A third of women did not recall receiving advice about diet as part of routine antenatal care. There is a need to develop a pathway to provide women with reliable, comprehensive advice about diet early in pregnancy., (Copyright © 2018 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Competing Interests: Disclosures: The author reports no conflict of interest with regard to this article.

Competing Interests: Author disclosures The author reports no actual or potential conflicts of interest with regard to this article.

Competing Interests: Author disclosures The author reports no actual or potential conflicts of interest with regard to this article.

Competing Interests: Author disclosures The author reports no actual or potential conflicts of interest with regard to this article.

More veterans are likely to present to the VA with service-connected claims for adverse effects related to exposure to a prophylactic antimalarial drug commonly used by the military for more than 2 decades., Competing Interests: Author disclosures Dr. Nevin has been retained as consultant and expert witness in legal cases involving claims of antimalarial toxicity. Dr. Ritchie reports no actual or potential conflicts of interest with regard to this article.

Objective: Feature articles in the Medical Surveillance Monthly Report (MSMR) reflect the U.S. military's health surveillance priorities. This study examined whether the recent rise in the number of ambulatory encounters for mental disorders in the U.S. military associated with the Iraq and Afghanistan wars was reflected in a proportional increase in MSMR feature articles on this topic., Methods: Articles published in the MSMR from January 1998 to December 2013 were examined to categorize feature articles according to health outcome. The proportion of articles by topic of outcome was compared with the proportion of all ambulatory encounters by category of disorder., Results: Mental disorders constituted 13% of ambulatory encounters and were the topic of 11% of 329 feature articles during the period, a statistically nonsignificant difference., Conclusions: The increased number of encounters for mental disorders has been met with a proportional but delayed increase in the number of MSMR feature articles focusing on these disorders.

Current treatments for PTSD are often not effective or acceptable to the patient. There are a number of emerging new treatments. One promising new one is stellate ganglion block, an anesthetic treatment for pain which relieves symptoms of severe and chronic PTSD in some patients. The focus of this chapter is to summarize clinical evidence available for the effectiveness of cervical sympathetic ganglion injection called stellate ganglion block (SGB), as well as demonstrate possible clinical applications of its use. Cervical sympathetic blockade involves injecting a local anesthetic next to a group of nerves (ganglion) in the neck. The technique has been used clinically since 1925 with very few side effects. Finally, the neurobiology of SGB is discussed. Challenges to the use of SGB include the lack of randomized clinical trials and practitioners familiar with the use of SGB for PTSD.

Background: Increasing use of intrauterine devices (IUDs) is seen as a promising strategy to prevent unintended pregnancies, particularly among young women. In this study, we examined correlates of young women's interest in using an IUD, including sources of information about, knowledge of, and attitudes toward IUDs., Methods: We conducted a national Web survey of young adults (ages 18-29) in 2012. Using a subset of data from 382 sexually experienced young women who had never used an IUD, we employed multinominal logit regression models to examine differences in IUD interest., Findings: Twenty percent of women in the sample were interested in using an IUD in the future, 32% were not, and 48% were unsure. Women who thought IUDs were unattractive owing to the devices being inside their bodies, the need for provider insertion and removal, or the potential for pain during insertion were less likely to be interested in ever using an IUD. Those who found IUDs attractive owing to the ease of use, the ability to have sex without interruption or a barrier method, the option of a nonhormonal method, the potential length of use, the internal nature of the method, or the high level of effectiveness were more likely to be interested., Conclusions: These data suggest that young women's attitudes toward IUDs are strongly linked to their interest-or lack thereof-in using an IUD. Health care providers attuned to women's contraceptive preferences are well-poised to help their patients match with methods that best accommodate these preferences., (Copyright © 2015 Jacobs Institute of Women's Health. Published by Elsevier Inc. All rights reserved.)

Early assessment data (starting at 9 months) for three children who were deaf or hard of hearing and later diagnosed with autism spectrum disorder (ASD) were analyzed. The results from the MacArthur-Bates Communicative Development Inventories (CDI) Words and Gestures and the Child Development Inventory were used to develop three profiles of children who were deaf or hard of hearing and had ASD. One child lacked expected skills and language at ages 9 and 14 months. Another child lost skills and language after 17 months. The third child had results usually within or above the average range until 3 years of age. However, his age quotient decreased for MacArthur-Bates CDI: Words and Gestures Words Expressed and the Child Development Inventory: Social to significantly below the normal range. Although it can be difficult to diagnose the co-occurrence of ASD and deafness, there were early warning signs for these children., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Purpose: Little is known about access to care for hematological cancer patients. This study explored patient experiences of barriers to accessing care and associated financial and social impacts of the disease. Metropolitan versus nonmetropolitan experiences were compared., Methods: A state-based Australian cancer registry identified adult survivors of hematological cancers (including lymphoma, leukemia and myeloma) diagnosed in the previous 3 years. Survivors were mailed a self-report pen and paper survey., Findings: Of the 732 eligible survivors, 268 (37%) completed a survey. Forty percent of participants reported at least one locational barrier which limited access to care. Only 2% reported cancer-related expenses had restricted their treatment choices. Almost two-thirds (64%) reported at least one financial or social impact on their daily lives related to cancer. The most frequently reported impacts were the need to take time off work (44%) and difficulty paying bills (21%). Survivors living in a nonmetropolitan location had 17 times the odds of reporting locational or financial barriers compared with those in metropolitan areas. Preferred potential solutions to alleviate the financial and social impacts of the disease were: free parking for tests or treatment (37%), free medications or treatments (29%), and being able to get treatment in their local region (20%)., Conclusions: Providing more equitable access to care for hematological cancer patients in Australia requires addressing distances traveled to attend treatment and their associated financial and social impacts on nonmetropolitan patients. Greater flexibility in service delivery is also needed for patients still in the workforce., (© 2013 National Rural Health Association.)

There is a substantial literature on the use of linkage disequilibrium (LD) to estimate effective population size using unlinked loci. The Ne estimates are extremely sensitive to the sampling process, and there is currently no theory to cope with the possible biases. We derive formulae for the analysis of idealised populations mating at random with multi-allelic (microsatellite) loci. The 'Burrows composite index' is introduced in a novel way with a 'composite haplotype table'. We show that in a sample of diploid size S, the mean value of x2 or r2 from the composite haplotype table is biased by a factor of 1-1/(2S-1)2, rather than the usual factor 1+1/(2S-1) for a conventional haplotype table. But analysis of population data using these formulae leads to Ne estimates that are unrealistically low. We provide theory and simulation to show that this bias towards low Ne estimates is due to null alleles, and introduce a randomised permutation correction to compensate for the bias. We also consider the effect of introducing a within-locus disequilibrium factor to r2, and find that this factor leads to a bias in the Ne estimate. However this bias can be overcome using the same randomised permutation correction, to yield an altered r2 with lower variance than the original r2, and one that is also insensitive to null alleles. The resulting formulae are used to provide Ne estimates on 40 samples of the Queensland fruit fly, Bactrocera tryoni, from populations with widely divergent Ne expectations. Linkage relationships are known for most of the microsatellite loci in this species. We find that there is little difference in the estimated Ne values from using known unlinked loci as compared to using all loci, which is important for conservation studies where linkage relationships are unknown.

Mefloquine (previously marketed in the United States as Lariam®) is an antimalarial medication with potent psychotropic potential. Severe psychiatric side effects due to mefloquine intoxication are well documented, including anxiety, panic attacks, paranoia, persecutory delusions, dissociative psychosis, and anterograde amnesia. Exposure to the drug has been associated with acts of violence and suicide. In this article, we discuss the history of mefloquine use and describe plausible mechanisms of its psychotropic action. Mefloquine intoxication has not yet been successfully advanced in legal proceedings as a defense or as a mitigating factor, but it appears likely that it eventually will be. Considerations for the application of claims of mefloquine intoxication in forensic settings are discussed.

Tephritid fruit flies, an important pest of horticulture worldwide, are increasingly targeted for control or eradication by large-scale releases of sterile flies of the same species. For each species treated, strains must be domesticated for mass rearing to provide sufficiently large numbers of individuals for releases. Increases in productivity of domesticated tephritid strains are well documented, but there have been few systematic studies of the genetic consequences of domestication in tephritids. Here, we used nine DNA microsatellite markers to monitor changes in genetic diversity during the early generations of domestication in replicated lines of the fruit fly Bactrocera tryoni (Froggatt) (Diptera: Tephritidae). The observed changes in heterozygosity and allelic richness were compared with the expected changes in heterozygosity generated by a stochastic simulation including genetic drift but not selection. The results showed that repeatable genetic bottlenecks occur in the early generations and that selection occurs in the later generations. Furthermore, using the same simulation, we show that there is inadvertent selection for increased productivity for the entire life on a mass-rearing colony, in addition to intentional selection for increased productivity. That additional selection results from the common practice of establishing the next generation of the breeding colony from a small proportion of one day's pupae collection (the pupal raffle). That selection occurs during all generations and acts only on fecundity variation. Practical methods to counter that unavoidable loss of genetic diversity during the domestication process in B. tryoni are discussed.

The suicide rate of active-duty soldiers doubled between 2003 and 2010. In response, the Department of Defense and the United States Army improved their data collection methods to better understand the causes of military suicides. As retired colonel Dr. Elspeth Cameron Ritchie writes, unit history and the accumulation of stressors-from relationship problems to chronic pain-are significant suicide risk factors among soldiers. But, she argues, Army officials must use this knowledge to design more-effective strategies for suicide reduction, including limiting access to weapons, especially post-deployment, and better connecting soldiers with their communities.

We used two mitochondrial loci (nicotinamide adenine dinucleotide dehydrogenase subunit 4 and cytochrome oxidase II) and a nuclear locus (28S-D2 spacer) for a total of 1337 bp to evaluate the relationships among the four subspecies of Aedes (Finlaya) japonicus Theobald. Ae. j. japonicus was recently introduced into the United States and has been expanding rapidly. We also included in our analysis a morphologically very closely related species, Aedes (Finlaya) koreicus Edwards, as well as three more distantly related species: Aedes (Finlaya) togoi Theobald, Aedes (Finlaya) hatorii Yamada, and Aedes (Aedimorphus) vexans Meigen. We found that the four subspecies in the Ae. japonicus complex are genetically quite distinct but seem to form a monophyletic group that surprisingly also includes Ae. koreicus, suggesting the need for a taxonomic reconsideration of the group. We also found that the two southern subspecies are more closely related to each other than to any of the remaining subspecies or to Ae. koreicus and may indicate an ancient north-south split of the lineage. Considering the overlap between Ae. j. japonicus and Ae. koreicus, but the stronger association between Ae. koreicus and humans, we are surprised it also has not expanded from its original range. As a proactive reaction to this possibility, we designed and tested a DNA-based rapid assay to differentiate Ae. koreicus from some of the species with which it may be confused in the United States. These Aedes are putative vectors of several important viral encephalitides.

Since 1985, a new and serious fruit fly pest has been reported in northwestern Australia. It has been unclear whether this pest was the supposedly benign endemic species, Bactrocera aquilonis, or a recent introduction of the morphologically near-identical Queensland fruit fly, B. tryoni. B. tryoni is a major pest throughout eastern Australia but is isolated from the northwest region by an arid zone. In the present study, we sought to clarify the species status of these new pests using an extensive DNA microsatellite survey across the entire northwest region of Australia. Population differentiation tests and clustering analyses revealed a high degree of homogeneity within the northwest samples, suggesting that just one species is present in the region. That northwestern population showed minimal genetic differentiation from B. tryoni from Queensland (FST=0.015). Since 2000, new outbreaks of this pest fruit fly have occurred to the west of the region, and clustering analysis suggested recurrent migration from the northwest region rather than Queensland. Mitochondrial DNA sequencing also showed no evidence for the existence of a distinct species in the northwest region. We conclude that the new pest fruit fly in the northwest is the endemic population of B. aquilonis but that there is no genetic evidence supporting the separation of B. aquilonis and B. tryoni as distinct species.

The U.S. military has long emphasized the principles of prevention and early intervention in preparing for and treating those afflicted by the psychological wounds of war. This article opens with lessons learned by the U.S. military through wartime during the past century. Current practice in the military's employment of stress control teams is reviewed. Updates in the military efforts in Operation Iraqi Freedom and Operation Enduring Freedom to prevent and to limit psychological casualties are stressed. Misconduct has occurred in this conflict; future steps to reduce aberrant behavior by soldiers are discussed. The challenges of reintegration at home, by both healthy and wounded soldiers, are highlighted.

Considerable literature exists on surveillance for medical effects of responses to a disaster but there is a dearth of information on conducting surveillance of behavioral health effects for first responders. This article reviews the literature and rationale behind behavioral health surveillance in the context of medical surveillance of first responders, examines special populations and ethical issues, discusses a model currently used by the U.S. military, discusses unresolved issues, and concludes with some practical suggestions.

Through the stimulus of war and concerns about neuropsychiatric disability, the U.S. military developed methods to rapidly screen the mental health of World War I and II draftees. Intelligence testing and brief psychiatric screening expanded the accession physical examination and underwent revision to identify only gross mental health disability. Supplemental psychiatric evaluations and written psychological screening tools were abandoned after postwar assessments; they demonstrated poor predictive power in evaluating recruit service capacity for combat environments. Currently, only three mental health accession tools are used to screen applicants before their entrance into military service, namely, educational achievement, cognitive testing, and a cursory psychiatric evaluation. The Navy and Air Force use a fourth screening measure during entry-level training. Educational attainment with high school graduation has been the strongest predictor of finishing a service term. The purpose of this article is to provide both a historical review and a review of testing efforts.

Background: Immediately before the first sailing of the USS Mercy/Project HOPE relief mission to Southeast Asia, the mission leadership initiated presailing orientation and training and a program of survey-based health surveillance for mission participants. The training and surveillance efforts included a focus on mental health aspects of the mission., Methods: At the conclusion of the predeployment mental health training, a voluntary, anonymous, predeployment survey was administered to members of the Project HOPE team. A second survey was administered approximately 3 months after return from the mission. The surveys were also administered before and after the second sailing of the USS Mercy/Project HOPE mission, although the training was not repeated., Results: The sample size prevented statistical analysis of predeployment and postdeployment rates of illness; however, there was no evidence of incidence beyond population baseline rates. Responses to questions regarding perceptions of mission success and personal achievement were quite favorable, whereas specific questions regarding shipboard resources, training, and professional interactions were met with more variable responses., Conclusions: Response rates suggest a strong interest among participants in efforts to address the Project HOPE program and resources. They also suggest resilience among participants and areas for improvement in communication among participants.

The United States has historically been concerned about the successful adjustment of its military members returning from war. These concerns are based on the recognition that war-zone exposures may have considerable negative emotional or behavior consequences. As the global war on terror continues, the United States military medical system will be required to address issues at the interface of psychiatry and the law. Despite clinical advances within the theater of war and at tertiary facilities in the United States, some military members will develop chronic and disabling mental illness as a result of traumatic exposure and exacerbated by the demands of the austere and dangerous operational environment. The extent to which violent and aggressive behavior in the aftermath of deployment can be attributed to combat experience remains an area of debate and ongoing investigation. However, experience suggests that a very small subgroup of the hundreds of thousands of war veterans deployed in conjunction with the current conflict in Iraq has already been involved in violent crimes. For this group, military forensic psychiatrists will be called on to make determinations of competency and criminal responsibility and to inform the courts about the potential contributions of war-related distress or disorder to criminal behavior. Though the overwhelming majority of war veterans will not be involved in criminal proceedings, a minority will develop career-ending (and in rare instances, life-ending) disabilities as a result of mental illness. For those who are no longer fit for duty, the military Physical Disability Evaluation System must make determinations of the extent to which future military performance and future civilian social and occupational function have been compromised. For a small yet highly visible minority of returning veterans, questions about the cause, precipitants, and manner of death will necessitate psychological autopsies. This article highlighted recent updates in military forensic psychiatry and the mechanisms through which answers to questions of disability and criminal culpability, and motivation underpinning self-injurious behavior, are determined within the United States military. As the global war on terror progresses, further experience and study of our country's judicial processes, disability system, and the policies and procedures governing psychological autopsies must evolve to meet these increasing demands.

This article reviews of some of the lessons in trauma psychiatry learned by the US military through wartime and other trauma experiences during the past century. Current practice in the military's employment of stress control teams is reviewed. The military's efforts to prevent and limit psychological casualties, to include the care of battle casualties and prisoners of war (POWs), are addressed. Recent experiences that have informed further, and are shaping the military's approach to managing the psychological aftermath of trauma (such as the Sept. 11, 2001, attack on the Pentagon and the current war with Iraq) are included. Guidelines developed after 9/11, and articulated in the "Mass Violence and Early Intervention" conference are presented. Finally, current ideas on preparation for and intervention after weapons of mass destruction will be outlined.

In stingless bees, sex is determined by a single complementary sex-determining locus. This method of sex determination imposes a severe cost of inbreeding because an egg fertilized by sperm carrying the same sex allele as the egg results in a sterile diploid male. To explore how reproductive strategies may be used to avoid inbreeding in stingless bees, we studied the genetic structure of a population of 27 colonies and three drone congregations of Trigona collina in Chanthaburi, Thailand. The colonies were distributed across six nest aggregations, each aggregation located in the base of a different fig tree. Genetic analysis at eight microsatellite loci showed that colonies within aggregations were not related. Samples taken from three drone congregations showed that the males were drawn from a large number of colonies (estimated to be 132 different colonies in our largest swarm). No drone had a genotype indicating that it could have originated from the colony that it was directly outside. Combined, these results suggest that movements of drones and possibly movements of reproductive swarms among colony aggregations provide two mechanisms of inbreeding avoidance., (Copyright 2004 Blackwell Publishing Ltd)

Based on past episodes, there will be psychological sequelae to chemical, biological, and radiological attacks. Some of the psychological morbidity should be able to be ameliorated through planning and appropriate early intervention. Key components of early intervention are illustrated following a hypothetical scenario of a bomb and anthrax threat near the Pentagon. Many of these components, such as monitoring clear, consistent messages about health risks, are provided by physicians or politicians, not mental health providers, but have a serious impact on the mental health of the population. We hope that this scenario and the principles of response will prove useful to planners of emergency preparedness and responders in the case of an actual attack.

Current literature suggests associations between abnormal mineral metabolism (MM) to cardiovascular disease in dialysis populations, with conflicting results. MM physiology is complex; therefore, it was hypothesized that constellations of MM parameters, reflecting this complexity, would be predictive of mortality and that this effect would be modified by dialysis duration (DD). Prevalent dialysis patients in British Columbia, Canada, who had measurements of calcium (Ca), phosphate (Pi), and parathyroid hormone (iPTH) between January and March 2000 were followed prospectively until December 2002. Statistical analysis included Cox proportional hazard models with Ca, Pi, and iPTH alone and in combination as explanatory variables; analyses were stratified by DD. The 515 patients included in this analysis represent British Columbia and Canadian dialysis populations: 69% were on hemodialysis, mean age was 60 +/- 17 yr, 40% were female, and 34% had diabetes. Mean Ca and Pi values were 2.32 +/- 0.22 mmol/L and 1.68 +/- 0.59 mmol/L, respectively, and median iPTH was 15.8 pmol/L (25th to 75th percentile: 6.9 to 37.3 pmol/L). Serum Pi, after adjusting for demographic, dialysis type and adequacy, hemoglobin, and albumin, independently predicted mortality (risk ratio [RR], 1.56 per 1 mmol/L; 95% confidence interval [CI], 1.15 to 2.12; P = 0.004). When combinations of parameters were modeled (overall P = 0.003), the combinations of high serum Pi and Ca with high iPTH (RR, 3.71; 95% CI, 1.53 to 9.03; P = 0.004) and low iPTH (RR, 4.30; 95% CI, 2.01 to 9.22; P < 0.001) had highest risks for mortality as compared with the combination of high iPTH with normal serum Ca and Pi that had the lowest mortality and was used as index category. These effects varied across different strata of DD. This analysis demonstrates the importance of examining combinations of MM parameters as opposed to single variables alone and the effect of DD. In so doing, the complex interaction of time and MM can begin to be understand. Further exploration is required.

Kenneth Leslie Artiss (1913-2001) was an Army psychiatrist who did significant investigative work in schizophrenia and milieu therapy and whose broad scholarship led to decisively important and enduring contributions to operational psychiatry. After retirement from military service, he developed a bold approach for teaching psychodynamic theory and its applications, and he led seminars for psychiatry residents and other physicians for over four decades. He was among the first to apply psychodynamic ideas to improve oncology practice. His death in 2001 motivated a group of his military students to memorialize his life and contributions and to demonstrate why they merit continuing consideration.

Increasing the incidence and duration of breastfeeding is a major goal in Healthy People 2010. Little is known about the progress that the Department of Defense (DoD) health care system, TRICARE, has made toward reaching that goal. This study is the first of a two-part series that reviews DoD/TRICARE support for breastfeeding and discusses policy issues related to breastfeeding. Methods used include searches of MEDLINE, DoD/TRICARE documents, legislative and policy websites, and the Internet. A survey of DoD hospitals was also conducted. Based on the search results and survey, TRICARE may not be meeting the goals of Healthy People 2010. There is minimal policy guidance regarding breastfeeding. Programs are in place at most hospitals, but the quality and content varies greatly. After mothers return to work, support is meager. DOD/TRICARE may need to establish written policy guidelines and devote additional resources to adequately support breastfeeding.

Breastfeeding is widely acknowledged as the ideal form of nutrition for infants. Because of this, increasing the incidence and duration of breastfeeding is a major goal in Healthy People 2010. Part I of this series illustrated that the Department of Defense and its health care system, TRICARE, may not be meeting that goal, particularly after active duty mothers return to work. This study outlines the resources that would be required to optimally support breastfeeding after active duty mothers return to work. Selected policy implications of supporting breastfeeding are discussed, and recommendations for policy on breastfeeding are presented.

It is unlikely that Gulf War veterans are suffering chronic effects from illnesses caused by chemical warfare nerve agent exposure. Extensive investigation and review by several expert panels have determined that no evidence exists that chemical warfare nerve agents were used during the Gulf War. At no time before, during, or after the war was there confirmation of symptoms among anyone, military or civilian, caused by chemical warfare nerve agent exposure. However, studies of Gulf War veterans have found belief that chemical weapons were used, significantly associated with both severe and mild-moderate illnesses. The psychological impact of a chemical warfare attack, either actual or perceived, can result in immediate and long-term health consequences. The deployment or war-related health impact from life-threatening experiences of the Gulf War, including the perceived exposure to chemical warfare agents, should be considered as an important cause of morbidity among Gulf War veterans.

Suicide is currently the second leading cause of death in the U.S. military. Little recent research has been done on a well-defined cohort at high risk for death by suicide, which consist of military patients who attempt suicide or are admitted for suicidal ideation. As a pilot investigation based on a literature review of suicidal behavior in the U.S. military, 100 consecutive charts of suicidal patients at a tertiary military treatment facility were reviewed. The findings included the following: 94% were admitted with a depressed mood; 67% had a history of previous attempts or gestures; 49% had been treated with psychiatric medication prior to admission and 88% were treated with psychiatric medications while on the ward; 47% returned to a full duty status; 29% were recommended for administrative separation; and 18% were recommended for a medical board. Suggestions for future research are presented to help improve our suicide prevention programs.

In the initial months of the Korean War, very high numbers of psychological casualties occurred among American troops, 250 per 1,000 per annum. Initially, these men were evacuated to Japan or the United States, and very few of them were returned to duty. Then the principles of early and far-forward treatment, learned in the previous world wars, were reinstituted. Up to 80% of neuropsychiatric casualties were returned to duty. During and after the war, the prisoners of war were believed to have been "brainwashed," have "give-it-upitis," and exhibit apathy and depression. Mistakenly believed to be signs of moral decay, the psychiatric symptoms during and after release were probably a result of extended inhumane treatment and vitamin deficiencies.

Psychological autopsies have been gathered by the US military for a long time, both for lessons learned after a known suicide and to investigate an equivocal death. The term "psychological autopsies" is now being restricted to define an investigation by mental health to help determine, in an equivocal death, if the manner of death is a homicide, suicide, an accident, or from natural causes. The Department of Defense has developed policy, and is now implementing training and peer review. A sample model curriculum, report format and quality assurance standards are included.

At the direction of the Army Surgeon General, the Army behavioral health consultants in psychiatry, psychology, and social work assembled in Washington, DC immediately after the September 11, 2001 attack to plan and implement a proactive behavioral health response to the Pentagon attack. The goal was to minimize the short- and long-term adverse behavioral health and related medical effects predicted to emerge based on past U.S. mass casualty scenarios. This article summarizes the goals, methods, and rationale used to develop the plan, as well as the key elements of the behavioral health intervention developed in response to the attack.

Operation Solace is the name given to a post-September 11, 2002 plan directed by the Army Surgeon General to proactively address the predictable behavioral health distress/disorders and related somatic phenomenon expected to occur among the Pentagon employees, family members, and Department of Defense beneficiaries located in the National Capitol Region affected by the terrorist attack. Using well-known and also relatively novel preventive population-based methodologies for minimizing the post-attack behavioral health-related morbidity resulted in the evolution of simplified principles ("Pieces of PIES") and methods (Therapy by Walking around and Care Management), which are briefly elaborated in this article.

Many teams from each of the different military services, as well as numerous civilian agencies, were involved in providing care to the victims, survivors, and family members of the September 11th attacks. However, the different teams initially had difficulties with communication and command and control issues. This article describes the perspective from Health Affairs on coordination of those efforts.

Humanitarian assistance is increasingly being offered by the military in operations other than war. Balancing issues of resources, priorities, and security is important but complicated. Sometimes errors are made that are costly, either in terms of public relations, morale, or lives. Unfortunately, not enough education of physicians and other medical personnel is done prior to the mission, as to how to weigh these aspects. No absolute guidelines can be recommended, as each situation is different, but some examples and guidelines are presented.