Hepatitis C Causes Brain Fog–Or Not? by Medical Student Timothy Kiong

Recently we had a nice presentation about the data regarding whether or not there is neuropsychological impairment secondary to hepatitis C virus itself in patients so infected.  This was presented by a senior medical student who was rotating on our Medical Psychiatry Unit as a subintern, Timothy Kiong.  The title of his talk was “Brain Fog: A brief summary of current studies in HCV-related psychiatric changes”.   Tim is interested in pursuing a medical-psychiatry combined residency program.

Tim presented some data regarding whether or not there is evidence to support the hypothesis that the hepatitis C virus itself can cause cognitive impairment, perhaps by an inflammatory mechanism.  We already know that the main treatment for hepatitis C, which happens to be alpha interferon, can cause a wide variety of neuropsychiatric adverse effects including depression and cognitive impairment.  We have already had one post by one of our family medicine residents about depression hepatitis C and interferon, please see link, Depression, Hepatitis C and Interferon: CPCP by Dr. Erin Schmidt – The Practical Psychosomaticist.


  • Hepatitis C virus is transmitted through blood products, exchange of body fluids, and sexual contact.
  • Hepatitis C effects about 2% of the world population.
  • About 75%–85% of cases go on to chronic infection.
  • About one third of injection drug users are infected with hepatitis C  (rate is higher in older ages)

Natural history:

  • Signs and symptoms of acute hepatitis C include fever, fatigue, dark urine and clay-colored stools, nausea and vomiting, and/or joint pain.
  • More commonly it is asymptomatic in chronic cases.

Laboratory assessments:

  • Hepatic transaminases are generally elevated.
  • Tests used to confirm infection include the anti-HCV, recombinant immunoblot assay (RIBA), and the polymerase chain reaction (PCR).

HCV-related neuropsychiatric changes:

  • Hepatic encephalopathy can be seen, in most cases a synonym for delirium.
  • 50% patient’s complaint of “brain fog”, weakness, fatigue, and general life impairment.
  • These changes seem to be irrespective of the genotype of HCV.

Studies supporting such a hypothesis:

  • 2001:  Forton and colleagues identified cerebral metabolic abnormalities in the frontal white matter and basal ganglia of HCV patients.
  • 2002:  Forton and colleagues identified significant impairment of concentration and working memory in 27 HCV PCR positive, anti-HCV positive versus HCV PCR negative, anti-HCV positive patients.
  • A number of studies demonstrated neuropsychiatric changes, but had confounders.
  • 2005:  McAndrews and colleagues identified minor attention and verbal learning impairments in 37 HCV patients without confounders (substance abuse, cirrhosis, depression).
  • 2010:  Lowry and colleagues identified 20 females in a homogenous cohort, 11 HCV RNA positive with poor scores in memory, as well as auditory and sustained attention.

Negative studies:

  • Two studies were done on healthy blood donors compared against those who were HCV positive by PCR. There were no differences in neuropsychiatric function.
  • Another study of subjects who had both hepatitis B and hepatitis C showed no differences in cognitive function.

Theories behind the dysfunction:

  • There could be direct neurotoxic effects.
  • There could be indirect neurotoxic effects mediated by systemic inflammation.


  • There have been varied studies with varying results and different confounding factors.
  • The subjects generally had persistently normal ALT for 6 months.
  • The case for HCV-related neuropsychological findings still appears to be a matter of debate.

Selected References:

Centers for Disease Control web site, Centers for Disease Control and Prevention

Forton, D. M., J. M. Allsop, et al. (2001). “Evidence for a cerebral effect of the hepatitis C virus.” Lancet 358(9275): 38-39.

Patients with hepatitis C virus (HCV) infection frequently complain of symptoms akin to the chronic fatigue syndrome and score worse on health-related quality of life indices than matched controls. We address the hypothesis that HCV itself affects cerebral function. Using proton magnetic-resonance spectroscopy we have shown elevations in basal ganglia and white matter choline/creatine ratios in patients with histologically-mild hepatitis C, compared with healthy volunteers and patients with hepatitis B. This elevation is unrelated to hepatic encephalopathy or a history of intravenous drug abuse, and suggests that a biological process underlies the extrahepatic symptoms in chronic HCV infection.

Forton, D. M., H. C. Thomas, et al. (2002). “Hepatitis C and cognitive impairment in a cohort of patients with mild liver disease.” Hepatology 35(2): 433-439.

Patients with chronic hepatitis C virus (HCV) infection frequently report fatigue, lassitude, depression, and a perceived inability to function effectively. Several studies have shown that patients exhibit low quality-of-life scores that are independent of disease severity. We therefore considered whether HCV infection has a direct effect on the central nervous system, resulting in cognitive and cerebral metabolite abnormalities. Twenty-seven viremic patients with biopsy-proven mild hepatitis due to HCV and 16 patients with cleared HCV were tested with a computer-based cognitive assessment battery and also completed depression, fatigue, and quality-of-life questionnaires. The HCV-infected patients were impaired on more cognitive tasks than the HCV-cleared group (mean [SD]: HCV-infected, 2.15 [1.56]; HCV-cleared, 1.06 [1.24]; P =.02). A factor analysis showed impairments in power of concentration and speed of working memory, independent of a history of intravenous drug usage (IVDU), depression, fatigue, or symptom severity. A subgroup of 17 HCV-infected patients also underwent cerebral proton magnetic resonance spectroscopy (1H MRS). The choline/creatine ratio was elevated in the basal ganglia and white matter in this group. Patients who were impaired on 2 or more tasks in the battery had a higher mean choline/creatine ratio compared with the unimpaired patients. In conclusion, these preliminary results demonstrate cognitive impairment that is unaccounted for by depression, fatigue, or a history of IVDU in patients with histologically mild HCV infection. The findings on MRS suggest that a biological cause underlies this abnormality.

Lowry, D., B. Coughlan, et al. (2010). “Investigating health-related quality of life, mood and neuropsychological test performance in a homogeneous cohort of Irish female hepatitis C patients.” Journal of viral hepatitis 17(5): 352-359.

Neurocognitive dysfunction has been reported in individuals with chronic hepatitis C (CHC) infection, but HCV populations investigated have often included participants with numerous potential confounding comorbidities. This pilot study sought to investigate functional capacity and neurocognitive function in a homogeneous state-infected HCV population with histologically defined mild liver disease, free from the comorbid factors typically associated with HCV populations. A further aim was to examine cognitive function in a treatment naive population with a similar history of iatrogenic HCV exposure and spontaneous viral clearance. A convenience sample of 29 women, all of whom were carefully screened to exclude relevant comorbidities, was recruited to the study. Twenty women with a history of iatrogenic HCV exposure were recruited from prospective specialist tertiary care liver clinics. A comparison group of healthy controls (n = 9) was also assessed. Study participants underwent mood, health-related quality of life and neuropsychological assessment. CHC patients reported significantly higher levels of cognitive fatigue than healthy controls (F = 3.4, P = 0.04). On cognitive testing, CHC patients showed impairments compared with healthy controls on estimates of general memory [F(2,25) = 4.1, P = 0.03, partial eta squared = 0.25], delayed auditory recognition [F(2,25) = 4.2, P = 0.03, partial eta squared= 0.22] and sustained attention [F(2,25) = 3.6, P = 0.04, partial eta squared = 0.22]. Increased cognitive fatigue only correlated with delayed auditory memory recall ability (r = 0.724, P = 0.006). In conclusion, these findings appear to support the presence of neurocognitive abnormalities in an iatrogenically infected, homogeneous female HCV population who were carefully screened to eliminate other factors affecting neurocognitive test performance and may indicate underlying neurophysiological causative mechanisms.

McAndrews, M. P., K. Farcnik, et al. (2005). “Prevalence and significance of neurocognitive dysfunction in hepatitis C in the absence of correlated risk factors.” Hepatology 41(4): 801-808.

Neurocognitive morbidity has been reported in individuals with chronic hepatitis C virus (HCV) infection, but the magnitude of such dysfunction in the absence of disease-correlated factors known to affect the central nervous system (e.g., substance abuse, cirrhosis, depression, interferon treatment) and the impact of any such change on functioning is unclear. We investigated a cohort of individuals with HCV, all of whom were carefully screened to exclude relevant comorbidities, to elucidate virus-related changes in the brain using neuropsychological tests and magnetic resonance spectroscopy (MRS). A cohort of 37 patients with chronic HCV infection was culled from 300 consecutive patients presenting to a tertiary care liver clinic. A comparison group of healthy controls (n = 46) was also assessed. Of 10 neurocognitive measures evaluated, the HCV group showed marginally poorer learning efficiency compared with controls; only 13% of patients demonstrated a clinical level of impairment on this test (defined as 1.5 SD below the normative standard). Although patients reported greater levels of fatigue and symptoms of depression, these factors did not correlate with the degree of learning inefficiency. With respect to MRS, the HCV group demonstrated increased choline and reduced N-acetyl aspartate relative to controls in the central white matter. Indicators of liver disease severity did not correlate with either memory or MRS abnormalities. In conclusion, while our findings support an association between hepatitis C and indicators of central nervous system involvement in a cohort of patients carefully screened to eliminate other factors influencing neurocognitive integrity, the clinical significance of these effects is limited.

Senzolo, M., S. Schiff, et al. (2011). “Neuropsychological alterations in hepatitis C infection: the role of inflammation.” World journal of gastroenterology : WJG 17(29): 3369-3374.

About 50% of patients with hepatitis C virus (HCV) infection complain of neuropsychiatric symptoms, “brain fog”, weakness, fatigue, and exhibit some degree of quality of life impairment, irrespective of the severity of liver disease. Since the first observation of HCV-related cognitive deficits, 10 studies have been published that have evaluated neuropsychiatric performance in patients with HCV infection and different degrees of hepatic impairment. Unfortunately, these have often included patients with cirrhosis, patients who had acquired the infection through previous intravenous drug misuse, who had a history of relatively recent treatment with interferon, or were on psychoactive medication. In addition, different neuropsychological batteries and tests that explored different cognitive domains were used, which makes the results of the studies difficult to compare. Finally, limited information is available on the pathogenesis of HCV-related cognitive impairment. Cerebral and/or systemic inflammation may be important players but their potential role has not been substantiated by experimental data. The present review outlines the available evidence of the presence of cognitive impairment in patients with HCV infection, with a focus on the potential relationship with cerebral and/or systemic inflammation. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3160562/pdf/WJG-17-3369.pdf

Capuron, L. and A. H. Miller (2004). “Cytokines and psychopathology: lessons from interferon-alpha.” Biological Psychiatry 56(11): 819-824.

Interferon-alpha is a potent inducer of the cytokine network and is notorious for causing behavioral alterations. Studies on interferon-alpha-treated patients reveal at least two distinct syndromes: 1) a mood/cognitive syndrome that appears late during interferon-alpha therapy is responsive to antidepressants and is associated with activation of neuroendocrine pathways and altered serotonin metabolism; and 2) a neurovegetative syndrome characterized by psychomotor slowing, and fatigue that appears early during interferon-alpha treatment is antidepressant nonresponsive and may be mediated by alterations in basal ganglia dopamine metabolism. Findings from interferon-alpha may provide important clues regarding the pathophysiology and treatment of cytokine-induced behavioral changes in medically ill patients, while also potentially modeling the development of neuropsychiatric symptoms in patients without medical disorders.

Capuron, L., G. Pagnoni, et al. (2005). “Anterior cingulate activation and error processing during interferon-alpha treatment.” Biological Psychiatry 58(3): 190-196.

BACKGROUND: There has been increasing interest in the role of immunologic processes, notably cytokines, in the development of behavioral alterations, especially in medically ill patients. Interferon (IFN)-alpha is notorious for causing behavioral symptoms, including depression, fatigue, and cognitive dysfunction, and has been used to investigate the effects of cytokines on the brain. METHODS: In the present study we assessed the effects of low-dose IFN-alpha on brain activity, using functional magnetic resonance imaging during a task of visuospatial attention in patients infected with hepatitis C virus (HCV). RESULTS: Despite endorsing symptoms of impaired concentration and fatigue, IFN-alpha-treated patients (n = 10) exhibited task performance and activation of parietal and occipital brain regions similar to that seen in HCV-infected control subjects (n = 11). Interestingly, however, in contrast to control subjects, IFN-alpha-treated patients exhibited significant activation in the dorsal part of the anterior cingulate cortex (ACC), which highly correlated with the number of task-related errors. No such correlation was found in control subjects. CONCLUSIONS: Consistent with the role of the ACC in conflict monitoring, ACC activation during IFN-alpha administration suggests that cytokines might increase processing conflict or reduce the threshold for conflict detection, thereby signaling the need to exert greater mental effort to maintain performance. Such alterations in ACC activity might in turn contribute to cytokine-induced behavioral changes.


Let’s Treasure Psychotherapy Training

One of the recent issues of Psychiatric News mentioned a study about trends of psychotherapy in residency training with the usual message reducible to two words–“needs work.” We need to treasure psychotherapy training.

The study is a survey with about 45% return rate [1]. There is a notable lack of sufficient numbers of well-trained teachers of psychodynamic, cognitive behavioral, and supportive psychotherapies. It wasn’t until 2001 that psychiatric residents were even required to learn minimum competencies in psychotherapy, in the age of biological treatments.

Then there are the time demands on psychiatry residents. It was like pulling teeth just to get them protected time for didactics. They’re too busy trying to navigate the intricacies of electronic health records (EHRs). Even when EHR management wasn’t such a time-consuming task, there were other challenges. I remember being required to obtain my psychotherapy supervision from a therapist downtown, meaning I would have to leave my inpatient care duties to…? The attendings? They were too busy writing research grants, which they needed to do in order to survive in an academic environment.

If delivering psychotherapy as a basic skill set is to remain a part of a psychiatrist’s identity, then everyone in academia and in the community must pull together to find a way to shoehorn this endeavor into the culture.

I’m reminded of Dr. Thomas P. Hackett’s view of what’s needed to build a psychiatric liaison (not just a consultation) service–“manpower, money, and motivation.”

And that’s why I’m excited about our recent departmental Grand Rounds presentation by one of our top performers, Dr. Scott Temple, PhD–because he’s got all three.

His subject was cognitive behavioral therapy (CBT) for patients with schizophrenia who suffer from hallucinations and delusions that are often medication-resistant. He emphasized what psychotherapy is all about by quoting Gerald May, “The deepest act of love is not help or service; it is immediate, attentive presence.”

This set the tone for the entire presentation and got the whole audience buzzing creatively, which is the effect Scott has on people. It’s not tough to see that May was talking about empathy. We tend to think of it as one of the touchy-feely qualities that sensitive people have. But empathy is measurable and empathy can do more than help psychiatric patients feel accepted in the therapist’s office. It can even help improve diabetes control, and I’m not talking about co-located psychiatrists in the primary care physician’s clinic. I’m talking about the primary care physicians themselves [2]. If empathy is measurable, than we ought to be able to teach it, right? Well, there are a lot of people who are going to be brainstorming about just that at the Gold Humanism Honor Society (GHHS) 5th Biennial Conference beginning October 4th and running through October 6th, 2012 at the Westin O’Hare in Rosemont, Illinois. One of the Keynote speakers, William Mobley, MD, PhD will deliver a presentation entitled “How Do We Educate Physicians to be Skilled in Empathy and Compassion?”, see my post Humanism in Medicine: GHHS 5th Biennial Conference – The Practical Psychosomaticist.

What does it take to achieve both the capacity for reflection and the receptiveness to epiphanies that Scott has, and the ability to teach them to others? There’s more to it than formal curricula. It’s sometimes the “hidden curricula” in the events which happen when we sit in the chair to be with a suffering patient, whether the malady is diabetes or schizophrenia. It’s the meaning of those events to teacher and learner, doctor and patient, that truly tells the story and reveals the path to the insight that we must be there for each other [3].

Psychotherapy doesn’t have to be complicated and the most important elements are probably less about technique than about warmth, understanding, listening. The simple rather than the complex seems to matter most to many patients, something like teaching patients the skill known for short as “Catch it; Check it; Change it”, http://www.peerzone.info/sites/default/files/resources/BBC%20Catch%20it,%20check%20it,%20change%20it.pdf.

As Scott talked, we all seemed to “catch” the idea of what may be the most important elements common to many psychotherapies, The Geezer’s Dirty Dozen on Common Elements of Psychotherapy – The Practical Psychosomaticist.

And some of Scott’s impressions can be gleaned from a previous blog as well, The Geezer’s Dirty Dozen on Cognitive Behavior Therapy – The Practical Psychosomaticist.

These blog posts and videos are in many ways inspired by Scott’s wisdom and practicality. His kind of energy, erudition, understanding, and warmth embody what we should treasure most about psychotherapy training. Our residents are all the better for it.

1. Sudak, D. M. and D. A. Goldberg (2012). “Trends in psychotherapy training: a national survey of psychiatry residency training.” Acad Psychiatry 36(5): 369-373.

OBJECTIVE The authors sought to determine current trends in residency training of psychiatrists. METHOD The authors surveyed U.S. general-psychiatry training directors about the amount of didactic training, supervised clinical experience, and numbers of patients treated in the RRC-mandated models of psychotherapy (psychodynamic, cognitive-behavioral therapy [CBT], and supportive). Questions regarding other models of psychotherapy and about challenges in training were also included. RESULTS The results demonstrate a wide range of experiences in psychotherapy education. Psychodynamic training is the most robust, but has the greatest variability. CBT training has advanced significantly over the past decade. Supportive psychotherapy is the most widely practiced, but receives the least amount of didactic time and supervision. CONCLUSION The authors discuss next steps in the evolution of psychotherapy education for psychiatrists.

2. Canale, S. D., D. Z. Louis, et al. (2012). “The Relationship Between Physician Empathy and Disease Complications: An Empirical Study of Primary Care Physicians and Their Diabetic Patients in Parma, Italy.” Academic Medicine 87(9): 1243-1249 1210.1097/ACM.1240b1013e3182628fbf.
Purpose: To test the hypothesis that scores of a validated measure of physician empathy are associated with clinical outcomes for patients with diabetes mellitus. Method: This retrospective correlational study included 20,961 patients with type 1 or type 2 diabetes mellitus from a population of 284,298 adult patients in the Local Health Authority, Parma, Italy, enrolled with one of 242 primary care physicians for the entire year of 2009. Participating physicians’ Jefferson Scale of Empathy scores were compared with occurrence of acute metabolic complications (hyperosmolar state, diabetic ketoacidosis, coma) in diabetes patients hospitalized in 2009. Results: Patients of physicians with high empathy scores, compared with patients of physicians with moderate and low empathy scores, had a significantly lower rate of acute metabolic complications (4.0, 7.1, and 6.5 per 1,000 patients, respectively, P < .05). Logistic regression analysis showed physicians’ empathy scores were associated with acute metabolic complications: odds ratio (OR) = 0.59 (95% confidence interval [CI], 0.37–0.95, contrasting physicians with high and low empathy scores). Patients’ age (≥69 years) also contributed to the prediction of acute metabolic complications: OR = 1.7 (95% CI, 1.2–1.4). Physicians’ gender and age, patients’ gender, type of practice (solo, association), geographical location of practice (mountain, hills, plain), and length of time the patient had been enrolled with the physician were not associated with acute metabolic complications. Conclusions: These results suggest that physician empathy is significantly associated with clinical outcome for patients with diabetes mellitus and should be considered an important component of clinical competence. The Relationship Between Physician Empathy and Disease Compl… : Academic Medicine, free article!

3. Kanter, S. L. (2012). “The Importance of Teaching and Learning Moments.” Academic Medicine 87(9): 1149 1110.1097/ACM.1140b1013e318269f318297b. The Importance of Teaching and Learning Moments : Academic Medicine, free article!

Somatoform Disorders: The Skinny


The link above takes you to a special format multimedia presentation I recently made about somatoform disorders. I hope that it will be available soon for Category 1 CME. It was made through materials from the University of Iowa Carver College of Medicine and with the help of information technology. I had originally asked that my Dirty Dozen YouTube presentations posted on my blog site be offered for CME, but there were too many ads on the YouTube videos. This is a nice format because you click on the Powerpoint slide and lose the Geezer video. You can also click on different time points in the show that are linked to the slides to review or skip forward. It’s nice to have options.

Best Hospitals: Joint Commission List 2012


I ran across the article in the Kaiser Health News Blog on the Joint Commission’s list of best hospitals for quality, Joint Commission Praises 620 Hospitals For Quality – Capsules – The KHN Blog. I must say I was pleased to find a couple of Iowa’s hospitals on the list, http://www.jointcommission.org/assets/1/18/Top_performers_2011_list_8_30_12.pdf. Many hospitals one would find on the U.S. News & World Report list of best hospitals (The University of Iowa is mentioned, see link Among the Nation’s Best Hospitals) are not on the Joint Commission’s list. I gather whether a hospital makes either list depends on what metrics are used for rating them.

The Kaiser Health News Blog points out that large academic medical centers would have a harder time making the Joint Commission’s list, although there’s no mention about why that should be the case. Moreover, there’s acknowledgement that the debate is far from conclusive about what standards actually are reflective of the best care for patients.

What is clear from my perspective as a faculty member in a teaching hospital is that we take the quality care measures very seriously and they are tracked closely, including the Hospital Based Inpatient Psychiatric Services (HBIPS) measures, HospitalBasedInpatientPsychiatricServices – Manual – Performance Measurement Network.

However, I don’t find Joint Commission metrics for delirium assessment, treatment and prevention processes and outcomes. One reason I can think of for that is the difficulty in collecting and extracting accurate occurrence rate data on delirium in the general psychiatry units as well as on the general medical and other medical subspecialty units. One way the University of Iowa Hospitals and Clinics might be ahead of the curve is our hospital’s participation in the multisite Modifying the Incidence of Neurologic Dysfunction (MIND) Study:

The Modifying the Impact of ICU-Associated Neurological Dysfunction-USA (MIND-USA) Study – Full Text View – ClinicalTrials.gov

Why it should it be so challenging to pin down the occurrence rates of delirium in the age of electronic health records (EHRs) is less than clear. But if a doctor doesn’t enter delirium on the patient’s Problem List, it’s very difficult to extract accurate data about it using even the Health Care Information Systems (HCIS) database system. In addition, data collection would be much easier if we used fewer diagnostic codes for delirium and used the term “delirium” instead of the many synonyms which abound. That’s why I’ve taken to heart Dr. Sharon Inouye’s call to all clinicians to identify delirium on the patient’s problem list in the chart, paper or electronic. This was one of Dr. Inouye’s central points in her keynote address at the 2nd Annual American Delirium Society conference in June of 2012, http://americandeliriumsociety.org/uploads/ADS_Newsletter_July_2012.pdf.

I think it’s puzzling that delirium assessment, treatment, and especially prevention is ignored by the Joint Commission given the basic facts we’ve had for decades about it, as outlined by the American Delirium Society (About Delirium):

“Delirium Simple Facts:
  • More than 7 million hospitalized Americans suffer from delirium each year.
  • Among hospitalized patients who survived their delirium episode, the rates of persistent delirium at discharge are 45%, 1 month 33%, 3 months 26%, and 6 months 21%. 
  • More than 60% of patients with delirium are not recognized by the health care system.
  • Compared to hospitalized patients with no delirium (after adjusting for age, gender, race, and comorbidity), delirious patients have:
  • Higher mortality rates at one month (14% vs. 5%), at six months (22% vs. 11%), and 23 months (38% vs. 28%);
  • Longer hospital lengths of stay (21 vs. 9 days);
  • A higher probability of receiving care in long-term care setting at discharge (47% vs. 18%), 6 months (43% vs. 8%), and at 15 months (33% vs. 11%);
  • A higher probability of developing dementia at 48 months (63% vs. 8%).”

More information about the quality care measures at the Joint Commission web site: http://www.jointcommission.org/hospital-based_inpatient_psychiatric_services/

Great Educational Video on PTSD: Introduced by Dr. Barbara Kamholz, MD

This is a great video for families about Post Traumatic Stress Disorder (PTSD) in older veterans made by the  Department of Veterans Affairs.  Dr. Barbara Kamholz, MD, a geriatric and consultation psychiatrist in the VA, introduces this educational video. There’s a lot of research going on about PTSD, and it’s on behalf of veterans and anyone else who’s suffered a traumatic event and is struggling in the aftermath, trying to move forward. One encouraging review offers smart, practical, and up-to-date guidance on what to do and maybe what not to do for those in the grip of PTSD [1]. Some of the highlights:

About one-third of the vulnerability to develop PTSD is genetically heritable although the rest of the remaining risk is mainly environmentally determined.

Compulsory debriefing of trauma victims is definitely not recommended and “should cease” because it can make the situation worse.

Benzodiazepine anxiolytics generally makes things worse for PTSD sufferers “and may even lead to higher rates of PTSD.”

Although self-help and psychoeducation approaches have not been shown to be effective, a video-based intervention prior to a forensic rape exam, a group intervention called Battlemind PD which emphasizes normalizing trauma reactions rather than recounting the traumatic event, and collaborative care models using cognitive behavioral therapy and motivational interviewing show promise.

Early prevention interventions which include extinction methods before fear consolidation can develop may be effective.

Future research can help by identifying those who might need early intervention versus those who might spontaneously recover.

I think it’s a wonderful way to say “never give up”.

1. Kearns, M. C., K. J. Ressler, et al. (2012). “EARLY INTERVENTIONS FOR PTSD: A REVIEW.” Depression and Anxiety.

The high prevalence of trauma exposure and subsequent negative consequences for both survivors and society as a whole emphasize the need for secondary prevention of posttraumatic stress disorder. However, clinicians and relief workers remain limited in their ability to intervene effectively in the aftermath of trauma and alleviate traumatic stress reactions that can lead to chronic PTSD. The scientific literature on early intervention for PTSD is reviewed, including early studies on psychological debriefing, pharmacological, and psychosocial interventions aimed at preventing chronic PTSD. Studies on fear extinction and memory consolidation are discussed in relation to PTSD prevention and the potential importance of immediate versus delayed intervention approaches and genetic predictors are briefly reviewed. Preliminary results from a modified prolonged exposure intervention applied within hours of trauma exposure in an emergency room setting are discussed, along with considerations related to intervention reach and overall population impact. Suggestions for future research are included. Prevention of PTSD, although currently not yet a reality, remains an exciting and hopeful possibility with current research approaches translating work from the laboratory to the clinic.

Announcement: Sign on to Mental Health Parity Letter!

Legislative Action Center | psychiatry.org

Please consider clicking on the link above and signing on to the Mental Health Parity Letter. The American Psychiatric Association Political Action Committee (APAPAC) has circulated a Take Action alert e-mail that will assist you in transmitting an e-mail letter urging your state representative to sign on to the Mental Health Parity, letter, which you can view at the link.

Pertinent excerpts from the message:

As we approach the fourth anniversary of the enactment of the Mental Health Parity and Addiction Equity Act (MHPAEA) on October 3, 2008, we are asking for your help to make the purpose of the federal parity law a reality.
Although MHPAEA was enacted nearly four years ago, a final rule implementing the law has not yet been issued. Without a final rule from the Administration, many individuals seeking care for mental health and addictive disorders have been unable to access the health care services they need.
A sign-on letter is being circulated through the House of Representatives by Reps. John Sullivan (R-OK) and Tim Ryan (D-OH) that reiterates important questions and urges the Obama administration to issue final rules. To view the ‘dear colleague’ letter dated Sept. 25, click here.
Your Requested Action:
Join us in the campaign and send a message to your Representative asking him or her to sign their name to this letter. APA Government Relations has provided a suggested message that contains all of the relevant information for your Representative and his or her staff. “

Delirium: The Skinny


This is a link to my multimedia presentation about delirium, which I hope will be available for category 1 CME in the near future.  It’s very similar to my Dirty Dozen on delirium, as some of you will notice. The University of Iowa Carver College of Medicine and I have been discussing doing something like this. I had originally intended to use my Dirty Dozen presentations as is, but the YouTube ads were a barrier. What’s nice about this format is that you can skip slides or review anytime in the show and even get rid of the Geezer video and concentrate only on the slides. Just click on the Powerpoint slide to lose the Geezer or click on any of the slide headers on the left to jump around. Have fun.