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The objective of this article is to critique a study conducted by the Swiss Federal Office of Public Health to evaluate Switzerland's heroin maintenance project. Heroin abusers (N = 1,146) were enrolled in 18 research clinics. Subjects were recruited into three study arms--heroin, morphine, or methadone maintenance, but randomization was unsuccessful, and all received heroin. Medications were self-administered by injection on site. Patients were interviewed at intake and 6-month intervals up to 18 months. A review of the study revealed design weaknesses, including the absence of control groups, lack of corroboration of self-reports, failure to control for the influence of social services on outcome, and the absence of follow-up on those who left the trial prematurely. The program's ability to avert human immunodeficiency virus (HIV) transmission could not be fully evaluated because patients did not consistently submit to HIV testing. The Swiss trials of supervised heroin prescription trials do not withstand scientific scrutiny. [ABSTRACT FROM AUTHOR]

One of us has hypothesised that the 'voices' of schizophrenic patients reflect altered preconscious planning of discourse that can produce involuntary 'inner speech' as well as incoherent overt speech. Some schizophrenic patients reporting voices do not, however, have disorganised speech. We hypothesise that these 'counterexample' patients compensate for impairments of discourse planning by reducing language complexity and relying on highly rehearsed topics. A 'language therapy' designed to challenge and enhance novel discourse planning was administered to four such patients; three had significant albeit temporary reductions in the severity of their voices. These clinical findings provide further evidence that alterations of discourse planning may underlie hallucinated voices. [ABSTRACT FROM AUTHOR]

A letter to the editor about the criteria for cocaine disorders is presented.

A letter to the editor on association of amphetamine use and the emergence of obsessive thoughts and compulsive behavior is presented.

A letter to the editor is presented in response to articles about the consequences of abrupt reduction of chronic symptoms, published in previous issues of the "American Journal of Psychiatry."

Virtually all clinicians agree that living donor renal transplantation is the optimal treatment for permanent loss of kidney function. Yet, living donor kidney transplantation has not grown in the United States for more than 2 decades. A virtual symposium gathered experts to examine this shortcoming and to stimulate and clarify issues salient to improving living donation. The ethical principles of rewarding kidney donors and the limits of altruism as the exclusive compelling stimulus for donation were emphasized. Concepts that donor incentives could save up to 40 000 lives annually and considerable taxpayer dollars were examined, and survey data confirmed voter support for donor compensation. Objections to rewarding donors were also presented. Living donor kidney exchanges and limited numbers of deceased donor kidneys were reviewed. Discussants found consensus that attempts to increase living donation should include removing artificial barriers in donor evaluation, expansion of living donor chains, affirming the safety of live kidney donation, and assurance that donors incur no expense. If the current legal and practice standards persist, living kidney donation will fail to achieve its true potential to save lives., Competing Interests: Declaration of Conflicting InterestsThe authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr Peters directs DCI Donor Services Research Fund and is a consultant for the Kidney Transplant Collaborative. Ms. Gershun is a Special Advisor to the Kidney Transplant Collaborative. The opinions expressed in this manuscript reflect those of the authors and not the institutions with which they are affiliated.

In the wake of the December 2012 mass shooting at an elementary school in Newtown, Connecticut, the Subcommittee on Oversight and Investigations of the Committee on Energy and Commerce of the U.S. House of Representatives held a hearing on the Substance Abuse and Mental Health Services Administration (SAMHSA) and its role in caring for people with severe mental illness. The author was among those who testified at the hearing. In this Open Forum she raises points made in that hearing-for example, that in embracing the recovery model and certain evidence-based practices, SAMHSA has been derelict in its duty to attend to the sickest individuals, those with chronic psychosis. She calls on the agency to embrace and promote a more balanced and pragmatic agenda.

From Brainwashed: The Seductive Appeal of Mindless Neuroscience by Sally Satel and Scott Lilienfeld, copyright © 2013. Reprinted by permission of Basic Books, a member of The Perseus Books Group. The notion that addiction is a "brain disease" has become widespread and rarely challenged. The brain-disease model implies erroneously that the brain is necessarily the most important and useful level of analysis for understanding and treating addiction. This paper will explain the limits of over-medicalizing - while acknowledging a legitimate place for medication in the therapeutic repertoire - and why a broader perspective on the problems of the addicted person is essential to understanding addiction and to providing optimal care. In short, the brain-disease model obscures the dimension of choice in addiction, the capacity to respond to incentives, and also the essential fact people use drugs for reasons (as consistent with a self-medication hypothesis). The latter becomes obvious when patients become abstinent yet still struggle to assume rewarding lives in the realm of work and relationships. Thankfully, addicts can choose to recover and are not helpless victims of their own "hijacked brains."

Incentives for organ donation, currently prohibited in most countries, may increase donation and save lives. Discussion of incentives has focused on two areas: (1) whether or not there are ethical principles that justify the current prohibition and (2) whether incentives would do more good than harm. We herein address the second concern and propose for discussion standards and guidelines for an acceptable system of incentives for donation. We believe that if systems based on these guidelines were developed, harms would be no greater than those to today's conventional donors. Ultimately, until there are trials of incentives, the question of benefits and harms cannot be satisfactorily answered., (© 2011 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Purpose of Review: The organ shortage is the major problem in kidney transplantation today. Despite aggressive organ procurement efforts, the supply of donated kidneys, living and deceased, has not matched the growing demand; as a consequence, more and more qualified candidates are suffering on dialysis and then dying before being transplanted. Herein, we provide justification for a regulated system of compensation for donation., Recent Findings: The main argument in favor of compensation is simple-financial incentives will increase donation, so fewer transplant candidates will suffer and die while waiting. In addition, development of a regulated system of compensation is the most effective means of crippling the core economic support for transplant tourism. Because dialysis is so much more expensive than a transplant, compensated donation could be cost-neutral to the healthcare system. Importantly, opinion polls suggest that the public would support compensation. As uncompensated kidney donation is widely accepted, persuasive arguments against compensation must explain why such a system would be morally distinguishable from uncompensated donation., Summary: We suggest that the potential advantages of a regulated system of compensation for donation far outweigh any potential disadvantages. It is time to advocate for a change in the law so that trials can be done.

The common-sense use of the term addiction is that regular consumption is irresistible and that it creates problems. Caffeine use does not fit this profile. Its intake does no harm to the individual or to society and its users are not compelled to consume it. Though cessation of regular use may result in symptoms such as headache and lethargy, these are easily and reliably reversed by ingestion of caffeine. Some have argued that continued caffeine use is an attempt to suppress low grade withdrawal symptoms such as sleepiness and lethargy. In some moderate users, this is possible; however, in experimental contexts, the phenomenon is too inconsistent to constitute a reliably valid syndrome.

The Institute of Medicine report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, claims that medical studies document a systematic causal relationship between race and disparities in health inputs and outcomes among individuals of different races. This article argues that the majority of studies are not powerful enough to establish a causal link, since they do not sufficiently control for differences among patients that happen to correlate with race, and it outlines a powerful audit study that could isolate any effect of race on health care decisions. Even if there are race-based disparities in health inputs, evaluations of welfare and policy prescriptions should be based on health outcomes, since the relationship between care and health is, at least in some cases, weak.

Cocaine is thought to act in the brain primarily by blocking dopamine re-uptake. The dopamine D3 receptor (genetic locus DRD3) is localized to brain regions that have been implicated in the reinforcing effects of a number of substances of abuse, including cocaine. The DRD3 coding region contains a polymorphism identifiable as a polymerase chain reaction restriction fragment length polymorphism (PCR-RFLP). This polymorphism leads to an amino acid substitution at position 9 in the extracellular N-terminus of the D3 dopamine receptor. We examined alleles of the DRD3 gene in cocaine dependence using a genetic association strategy in samples of 62 white and 62 black cocaine-dependent individuals. Comparisons were made with local (Connecticut) control subjects for both groups, and with a larger sample of literature controls (for the white subjects) and a contrast group of schizophrenic patients (for the black subjects). No association was found between cocaine dependence and DRD3 alleles in either group (Bonferroni corrected). There was a significant difference in allele frequency between whites and blacks. These results are consistent with no role for genetic variation of the D3 dopamine receptor in susceptibility to cocaine dependence.

Objective: Although cocaine is a potent serotonin (5-HT) reuptake blocker, the role of 5-HT systems in cocaine craving and relapse in humans has been unclear. The authors evaluated whether acute reductions in central 5-HT synthesis modulated craving for cocaine in cocaine-dependent patients., Method: Twenty-five cocaine-dependent male inpatients were exposed to cocaine-craving cues while their 5-HT levels were lowered and during a placebo condition in a counterbalanced, double-blind design. 5-HT levels were reduced by rapidly lowering plasma levels of its precursor, tryptophan; tryptophan levels were reduced by stimulating protein synthesis with a large drink of amino acids devoid of tryptophan. During the placebo condition the patients drank an identical amino acid drink containing tryptophan. Craving was induced by exposing patients to cocaine paraphernalia and a videotape depicting drug use. Craving was assessed 7 hours after ingestion of the drink. Visual analog ratings of craving for cocaine were administered before and after cue exposure at each test session., Results: Patients reported less desire for cocaine stimulated by cue exposure after drinking amino acids without tryptophan than they did after drinking placebo. The order that tryptophan depletion and placebo tests were performed influenced the impact of tryptophan depletion on cue-induced craving., Conclusions: Serotonergic systems modulate cue-induced craving for cocaine, a factor implicated in relapse to cocaine use.

Paranoia in the context of cocaine abuse is common and potentially dangerous. Several lines of evidence suggest that this phenomenon may be related to function of the dopamine transporter protein (DAT). DAT is the site of presynaptic reuptake of dopamine, an event that terminates its synaptic activity. The gene coding for dopamine transporter protein (DAT1) contains a variable number of tandem repeats (VNTR) polymorphism in the 3' untranslated region that can be typed by the polymerase chain reaction (PCR) (Vandenbergh et al. 1992). Although this is not a coding region polymorphism, it is close to the coding region and could plausibly be in linkage disequilibrium with a mutation in the gene. Cocaine blocks the dopamine transporter and increases synaptic availability of dopamine. We examined DAT alleles in 58 white and 45 black cocaine users in order to test only two hypotheses: (1) Is there an allelic association between DAT and cocaine dependence? and (2) Is there an allelic association between DAT and cocaine-induced paranoia? We did not demonstrate an allelic association with cocaine dependence. However, within the white sample, DAT genotype was associated with cocaine-induced paranoia (allele frequency for allele 9 = .16 for those without paranoid experiences versus .35 for those with, chi 2 = 3.9 [2 x 2 table], p < .05). There was no significant difference for the same measure in the black sample. Certain DAT genotypes may therefore predispose to paranoia in the context of cocaine use in white populations. We caution that these results require independent replication.

Previous research has shown a high prevalence of comorbid personality disorders among individuals seeking treatment for cocaine dependence. We studied axis II disorders (using the Structured Clinical Interview for DSM-III-R Personality Disorders [SCID-II]) in 50 patients admitted for inpatient rehabilitation. All patients met lifetime criteria for cocaine dependence and reported cocaine use during the month before admission. Seventy percent of patients met criteria for at least one axis II diagnosis; the mean number of axis II diagnoses among these patients was 2.54 (range, one to six). The most common axis II diagnosis was borderline (34% of all patients), followed by antisocial and narcissistic (each 28%), avoidant and paranoid (each 22%), obsessive-compulsive (16%), and dependent (10%). To evaluate the relationship between comorbid personality pathology, substance abuse, and other psychiatric symptomatology, patients were divided into two groups based on whether they received an axis II disorder diagnosis. The groups did not differ on substance abuse variables. However, there were significant group differences on a measure of psychosis proneness and in the number of comorbid depressive and anxiety disorder diagnoses. These results are consistent with other studies of personality disorders in substance abuse patients, and suggest that it may be clinically useful to characterize cocaine-dependent patients with respect to comorbid axis II disorders.

Alcohol use is prevalent among Vietnam veterans who suffer from chronic combat-related posttraumatic stress disorder (PTSD). Although Alcoholics Anonymous (AA) is the mainstay of ambulatory alcoholism treatment, adherence to particular components of the AA philosophy may prove especially challenging for alcoholic Vietnam veterans with PTSD. The authors describe elements of AA's philosophy, such as "surrendering" to a "higher power," making amends to persons one has harmed, and sharing one's story publicly, that may be difficult for the Vietnam veteran with PTSD. The authors suggest that an important factor in the successful affiliation of these patients with AA is their capacity to separate their alcohol-related problems and treatment from their PTSD symptoms and treatment and to accommodate dual identities as both an alcoholic and a traumatized soldier. Preparing such patients for AA by reframing some of the 12 steps is recommended.

Objective: The authors reviewed both clinical data and selected laboratory research related to withdrawal from alcohol, opiates, and stimulants in order to draw a conclusion about whether the phenomenon of protracted withdrawal exists and should be included in DSM-IV., Method: Studies were located through computerized searches and reference sections of published articles., Results: Symptoms extending beyond the period of acute withdrawal in alcohol and opiate dependence have been fairly consistently described; this is not the case with cocaine. Nevertheless, protracted alcohol and opiate withdrawal has not been conclusively demonstrated because of the failure of studies to do multiple time point sampling, to use standardized instruments and control groups, and to re-administer the substance in an attempt to suppress withdrawal symptoms. Further, the concept of protracted withdrawal itself is ambiguously defined. This confounds interpretation of the literature and precludes derivation of a unified concept of the term, which would be necessary for adding the diagnosis to DSM-IV., Conclusions: There is insufficient documentation to justify inclusion of protracted withdrawal in DSM-IV because of methodologic limitations of the studies and lack of consensus definition of the term itself. An outline for conceptualizing protracted withdrawal is offered in which the symptoms can be seen as: 1) a global post-use syndrome, 2) attenuated physiologic rebound, 3) toxic residuals, 4) expression of preexisting symptoms unmasked by cessation of use. Future efforts to identify signs and symptoms of protracted withdrawal should carefully define the parameters of the syndrome.

Objective: This study was undertaken to document symptoms and changes in dopaminergic function emerging after abrupt cessation of cocaine use., Method: After admission, 22 patients with DSM-III-R cocaine dependence were observed drug free for 3 weeks. The patient-rated Ribicoff Abstinence Rating Scale, Symptom Rating Scale, Physical Symptom Scale, Patient Rated Anxiety Scale, Beck Depression Inventory, and visual analogue scales for 16 subjective states were completed daily, and nurses rated 13 patients with the global anxiety and depression items of the Short Clinical Rating Scale. Serial blood samples were obtained three times weekly, and the patients' levels of prolactin, growth hormone (GH), and homovanillic acid (HVA) were measured. Their prolactin and GH values were compared with those of matched normal subjects., Results: A total of 62 subjective symptom variables were evaluated. At baseline, the symptom ratings were mildly elevated. At 3 weeks there were significant decreases from baseline in 28 variables and nearly significant decreases in six additional variables. Nurse-rated anxiety and depression also changed, but in a more variable pattern. There was a small but significant increase from baseline over time in plasma prolactin, but there were no significant changes in GH or HVA. The patients' prolactin and GH values did not differ from those of the normal subjects., Conclusions: These findings suggest that symptoms after inpatient cessation of uncomplicated cocaine addiction are relatively mild and decrease linearly over the first month. Evidence of dysregulated central dopamine function was limited. The findings do not support routine use of pharmacological agents in the inpatient management of such patients.

Objective: The aim of this study was to determine whether individuals who experience transient cocaine-induced paranoia are vulnerable to psychosis., Method: The subjects were 20 cocaine-dependent men who had been using more than 5 g of cocaine per week and were undergoing substance abuse treatment; half reported binge-limited cocaine-induced paranoia. The men were assessed with the Perceptual Aberration Scale and the Magical Ideation Scale, self-report measures of symptoms thought to precede the development of functional psychosis., Results: The combined scores on the Perceptual Aberration Scale and Magical Ideation Scale were strongly correlated with a history of cocaine-induced paranoia. The sensitivity, specificity, and positive and negative predictive power were 80.0%, 90.0%, 88.9%, and 81.8%, respectively., Conclusions: Heavy cocaine users who experience transient paranoia while intoxicated may be at higher risk for development of psychosis than cocaine users who do not experience paranoia.

Objective: The authors' objective was to assess the frequency and nature of cocaine-induced paranoia., Method: They interviewed 50 cocaine-dependent men consecutively admitted to a 28-day rehabilitation program., Results: Thirty-four (68%) of the 50 men reported highly distressing transient paranoid states in the context of cocaine use. The men who experienced paranoia did not differ from those who did not in age, race, or measures of cocaine use. The mean duration and amount of cocaine use before development of paranoia of the men who reported paranoia were not significantly different from the mean lifetime duration and amount of cocaine used by the men who did not report paranoia. Paranoia became more severe and developed more rapidly with continued cocaine use., Conclusions: The transient paranoid state appears to be a common feature of cocaine dependence and does not seem to be simply a result of exceeding a threshold of use. Rather, affected individuals might possess a predisposition to this drug-induced state. The fact that paranoia became more severe and developed more rapidly with continued drug use is consistent with a sensitization model of cocaine-induced paranoia. In vulnerable individuals, limbic sensitization may underlie its expression, but localization to a specific brain region is speculative. Quantity of use and route of administration do not appear directly to predispose to this phenomenon. Future investigations must be aimed at uncovering the markers and meaning of vulnerability to transient paranoia in heavy cocaine users.

Glucocorticoid preparations are used commonly in the treatment of many diseases in children and adolescents. Although their physiologic side of effects have been described well, the psychiatric side effects of these medications have received little attention. Limited data suggest that disturbances of affect and behavior may occur in 25-50% of children receiving glucocorticoid. These steroid-induced mental changes may be underrecognized in children, and yet these changes can have considerable impact on social and psychological functioning and treatment outcome. An enhanced awareness and reporting of this phenomenon by clinicians, parents, and teachers would likely lead to better compliance with treatment, improved outcomes, and greater understanding of emotional concomitants of illness.

In this paper we encourage the evaluating clinician to approach substance abuse as though it were a symptom, like any other, that serves a psychological function for the borderline individual. During the assessment phase, this approach is likely to (1) generate interest among treaters (2) solidify rapport with the patient resulting in a positive attitude toward the assessing clinician with more informative self-reports, (3) elucidate, for the clinician, the patient's major deficits in personality structure, especially the inability to understand and control affective states, and (4) stimulate the patient's curiosity about the way in which emotions are perceived and processed.

The authors report on the use of playing back audiotaped portions of the speech of two schizophrenic patients during psychotherapy. They believe that this audiotape replay was instrumental in organizing the patients' thoughts and spoken communications and that it might also have facilitated the patients' participation in psychotherapy. The usefulness of this strategy is illustrated with clinical material.