Epidemiology and Public policy Part 1 Question Bank Flashcards
(19 cards)
15 years after recovering from an index episode of depression, what percentage of patients will have had a recurrence of their depression?
85% - earlier statistics had a 50% chance of recurrence after one episode and an 80% chance after two episodes, but now it ranges between 50-80% (and given enough time, 85% chance). The chance of recurrence after 3 episodes is 90%. If antidepressants are withdrawn in less than 3 months, symptoms usually recur. Note that the intervening period between depressive episodes decreases with age and that as many as 50-85% will have at least two episodes of depression. The general rule is to treat for at least 6 months after successful recovery from one episode of depression, to treat for 1-2 years after recovery from two episodes of depression, and to treat for 3-5 years or indefinitely for 3 or more episodes of depression.
A 7-year-old African American child is being evaluated for academic difficulties. The child was adopted at birth by a married couple who are Caucasian-American. The adoption is an open one and the child has met the biological grandparents who are supportive of the adoption. One biological parent has bipolar disorder. Which of the following confers the highest risk for psychopathology for this child?
Right Answer: Having biological relatives with psychiatric illness
A female athlete in high school asks her counselor which sport carries a lower risk of concussion. She is interested in volleyball, boxing, ice hockey, wrestling, lacrosse, soccer, and basketball. Which sport should the psychiatrist recommend?
Of the choices listed, volleyball carries the lowest risk of concussion.
A risk factor for violence includes:
untreated psychosis
Most patients with schizophrenia are not violent, and most episodes of violence do not result in any significant injury. However, schizophrenia, especially untreated psychosis, is a risk factor for violence. A review of violence during a first episode of psychosis found that one-third of persons in their first episode of psychosis commit an act of violence before entering treatment (Nielssen et al. 2012). One in six patients experiencing a first psychotic episode commits an act of serious violence (i.e., assault causing any degree of injury, sexual assault, or assault with a weapon).
Among the anxiety disorders, which is the most common?
Among the anxiety disorders, the phobias - particularly specific phobia and social anxiety disorder (SAD) - are the most common conditions, with lifetime prevalence rates greater than 10%. Panic disorder, generalized anxiety disorder (GAD), agoraphobia, and separation anxiety disorder (SepAD) each have lifetime prevalence rates between 2% and 7%. SAD and specific phobia have a lower median age at onset than the other anxiety disorders.
Among the following disorders, the one with the highest 12-month prevalence among men and women ages 65 years and older in the U.S. is:
The disorder with the highest 12-month prevalence among participants ages 65 years and older reported from the NESARC was specific phobia (7.5%) (Stinson et al. 2007), whereas the disorder with the highest lifetime prevalence was any alcohol use disorder (16.1%) (Hasin et al. 2007).
Among the mental disorders, which disorders are the most prevalent conditions in any age category?
Among the mental disorders, anxiety disorders are the most prevalent conditions in any age category.
Children with fecal incontinence are more likely to have comorbid psychiatric symptoms. Which is most common?
oppositional defiant disorder
Children with fecal incontinence are more likely to have comorbid psychiatric symptoms. They have higher rates of oppositional defiant disorder (11.9%), ADHD (9.2%), separation anxiety (4.3%), specific phobias (4.3%), and generalized anxiety (3.4%). They also have subclinical symptoms, including lower self-esteem and lower social functioning, as well as feeling less able to control the positive aspects of their lives (von Gontard and Nevéus 2006).
During a suicidal risk assessment, a patient lists several risk factors. Which of the following is not a protective factor?
In formulating a suicide risk assessment, it is important to note protective factors in addition to the presence or absence of acute and chronic risk factors. One study of depressed patients without a history of suicide attempts found that the following served as protective factors: an expression of more responsibility toward family, more fear of social disapproval, more moral objections to suicide, greater coping skills, and greater fear of suicide (Malone et al. 2000). Social connectivity also serves a protective role for depressed patients, as first described by Emile Durkheim (1951). Having close familial relationships, living with another person (family or friend), and having dependent children are all protective factors. Being involved in cultural groups such as organized religion and having moral objections to suicide are associated with lower rates of suicide (Dervic et al. 2004, 2006).
During a suicidal risk assessment, a patient lists several risk factors. Which of the following is a dynamic risk factor?
A dynamic risk factor is one that can change over time, such as an intoxicated state or acute psychiatric instability. Among the choices, only substance intoxication is a risk factor that can change over time. All other choices happened in the past and cannot be changed. While recent discharge from a psychiatric hospital is an acute risk factor, it is considered static since it has already happened in the past.
During a suicidal risk assessment, a patient lists several risk factors. Which of the following is a chronic risk factor?
Chronic risk factors for suicide set the background on which acute risk factors are evaluated. They are derived from population-based analyses of suicides and often are not amenable to any therapeutic intervention, since they are primarily demographic characteristics of people who have died by suicide (Kessler et al. 1999; Moscicki 1997). Males complete suicide four times more often than females do, but females attempt suicide three times more often than males. Males tend to choose more lethal and vio-lent means of suicide than do females. Among males, firearms are the most commonly used (57.6%) method of suicide (National Center for Injury Prevention and Control 2005). Individuals age 65 years and older constitute 13% of the population but account for 19% of the suicides, making older age a significant chronic risk factor. The suicide rate for white men older than 85 years is 65 deaths per 100,000 population. A coincident risk factor is chronic illness, especially if it was diagnosed in the previous year. Another at-risk group is teenagers and young adults between the ages of 18 and 24 years, in whom suicide is the third leading cause of death.
Whites complete suicide two times more often than nonwhites, with white males accounting for 73% of the suicides in 1998 (National Center for Injury Prevention and Control 2002). The suicide rates for Native Americans are 1.5 times the national average. Suicide rates for specific ethnic groups change with the age and gender of the individual, so blanket statements of risk are not necessarily accurate. In one study, African American males constituted the largest group, numerically and statistically, of teenage suicide victims but accounted for only 26% of victims from all age groups. In this same data set, African American females accounted for only 3% of all suicides, with only one occurring in an individual older than 45 years (Garlow et al. 2005).
Approximately 90%–95% of suicide victims have a major psychiatric illness, of which approximately half have a mood disorder (Angst et al. 2002; Fawcett 1992; Harris and Barraclough 1997). Male bipolar patients are at higher risk, especially those at an earlier phase of the illness, those who are currently in a depressed state, and those with comorbid substance abuse (Simpson and Jamison 1999). Patients with alcohol and other substance use disorders have higher rates of completed suicide than the national average, with alcoholic patients having a suicide rate twice the national average (Fowler et al. 1986). For alcoholic patients, comorbid depression and recent interpersonal loss increase risk (Murphy and Wetzel 1990; Murphy et al. 1992). A family history of suicide increases suicide risk independent of a family history of mental illness (Qin et al. 2002, 2003).
Patients with personality disorders often express ongoing suicidal ideation; as a result, suicidality becomes embedded in their sense of self (Soloff et al. 1994). This can manifest as repeated acts of parasuicidal or gestural self-injurious behavior, such as cutting and sublethal overdoses. These patients can be very difficult to manage and can put a great deal of strain on the mental health services delivery system. A consistently applied treatment plan, restrained responses on the part of clinicians and staff (minimizing countertransference behaviors), and use of secure 24-hour patient observation areas can be particularly useful in managing these patients. The goal is to allow patients to deescalate and calm down so that they can ultimately be discharged back into their ongoing outpatient treatment regimens (Maltsberger and Buie 1974).
During a suicidal risk assessment, a patient lists several risk factors. Which of the following is an acute risk factor?
recent discharge from a psychiatric hospital
Acute risk factors are much more predictive of emergent suicidality than chronic risk factors. Acute risk factors include increasing anxiety and frank panic attacks, psychic turmoil, global insomnia, mood-congruent nihilistic delusions, profound hopelessness, and recent discharge from a psychiatric hospital (Busch et al. 2003; Fawcett 1992; Fawcett et al. 1990). Patients who are experiencing the first three of these symptoms should be viewed as being at particularly high risk regardless of whether they verbalize suicidal ideation. In terms of recent psychiatric hospitalization, the 3-month period following discharge poses a significant period of vulnerability, with one population study indicating 7.8% of the suicide victims completed suicide within 1 month of discharge (Deisenhammer et al. 2007).
Active substance intoxication is another acute risk factor. Recent alcohol consumption plays a role in 25%–50% of all suicides, and the consumption of both alcohol and cocaine may be particularly dangerous (Cornelius et al. 1998). Alcohol intoxication is related to higher rates of completed suicide, while cocaine intoxication is related to higher rates of suicidal ideation (Garlow 2002; Garlow et al. 2003). In this comprehensive series of suicide victims, 40% had alcohol or cocaine detected at the time of autopsy, indicating that the substance was consumed within 48 hours of death (Garlow 2002). Fully 21% of these suicide victims had blood alcohol levels above the legal limit for intoxication (0.08 μg/mL). Cocaine intoxication doubles the risk of suicide in white teenagers compared with African American teenagers (Garlow et al. 2007).
Previous suicide attempts are known precursors for completed suicide; thus, nonlethal suicide attempts are acute risk factors (Deisenhammer et al. 2007; Isometsä and Lönnqvist 1998; Tejedor et al. 1999). The risk for completion is notably higher in the time period following a suicide attempt (Conwell et al. 1996). Consideration should be given to the actual lethality of the attempt; the patient’s perception of that lethality; efforts made by the patient to ensure detection or nondetection; calls for help by the patient to medical or law enforcement agencies; contacts to friends or family during the attempt; and use of a firearm. All of these factors illuminate the actual suicidal intent of a patient. A person who took a lethal overdose in a secluded location with no contact to others and who was discovered by accident represents a much higher risk than a person who took a sublethal overdose in a witnessed situation or who immediately called someone to report the overdose or ask for help. Access to firearms must always be determined in a suicide attempt and in someone who appears to be at high risk (Conwell et al. 2002; Miller et al. 2002; Romero and Wintemute 2002).
Other behaviors that should be noted include giving away possessions, placing financial and legal affairs in order, and showing extreme social withdrawal or severing previous interpersonal relationships. Reliable assessment of these behaviors requires collateral history from individuals close to the patient.
Heroin use is least associated with which population-wide adverse risk?
motor vehicle accidents
The adverse risks associated with heroin use include overdose, blood-borne virus transmission, criminality, trauma, and suicide, as well as cardiovascular, liver, and pulmonary diseases (Degenhardt and Hall 2012).
In developed countries, which of the following is alcohol use disorder associated with the least?
being married
In developed countries, having an alcohol use disorder is associated with being male, young, and unmarried as well as being of low socioeconomic status (SES). In the majority of cases, the onset of alcohol abuse and dependence occurs before age 30. These disorders are highly comorbid: up to half of those diagnosed with an alcohol use disorder also had a second diagnosis, whether that be a substance-related, affective, or anxiety disorder.
In the United States, stimulant dependence is associated with each of the following except:
older age at onset of use
In the United States, stimulant dependence is associated with younger age, as well as younger age at onset of use, being white or Hispanic, and residing in western or southern U.S. regions.
Since the mid-1970s, there has been significant improvement in rates of survival from traumatic brain injury (TBI). Which of the following is <em>not </em>a significant contributor to this trend?
Right Answer: a growing population of TBI survivors with a broad array of neurological deficits
Prior to 1980, there was essentially no public policy specific to TBI (Spivack 1994). Since the mid-1970s, there has been significant improvement in rates of survival from TBI, a result of better emergency care at accident sites, improved access to specialized trauma centers, and technological advances such as intracranial pressure monitors and magnetic resonance imaging scans. A growing population of TBI survivors with a broad array of neurological deficits is a result of this trend, not a contributing cause.
The 1-year incidence of Alzheimer’s disease in the U.S. can be best characterized by which of the following statements?
Right Answer: 0.6% in individuals ages 65–69 years and 8.4% in those ages 85 years and older
There exists an increase with age in the 1-year incidence of Alzheimer’s disease as reported from the East Boston EPESE: 0.6% in individuals ages 65–69 years and 8.4% in those ages 85 years and older (Hebert et al. 1995).
The black box warning by the U.S. Food and Drug Administration regarding the potential increased risk of suicidal ideation from SSRIs does not apply to which population?
adults
A relationship between antidepressant use and suicidal behaviors has been reported in the media and psychiatric literature. The impetus for this focus was the addition of a black box warning by the U.S. Food and Drug Administration (FDA) on the potential increased risk of suicidal ideation in children, adolescents, and young adults treated with SSRIs.
The highest rates of amphetamine use are located in which regions?
Oceania, North America, and Asia have the highest rates of amphetamine use
