This chapter contains sections titled: The Efficacy and Effectiveness of Psychotherapy How Psychotherapy Works Combining Drugs and Psychotherapy Choosing among Alternatives Why Psychotherapy is not Prescribed Access and Quality Control Ideology and Practice Bringing Psychotherapy Back into Psychiatric Practice
September 11, 2001 demonstrated dramatic voids in national preparedness, and catalyzed massive efforts to identify and remedy vulnerabilities. Since Part I of this series appeared in August 2002, significant improvements have been achieved especially in bioterrorism and chemical terrorism for first responders and emergency medicine, law enforcement, and public health (surveillance). Such efforts manifested benefits during the SARS outbreaks and monkeypox cases of 2003. Nevertheless, emerging infectious diseases will continue to pose a threat if we do not remain vigilant and continue to invest in training, surveillance, and treatments. As expected, many poison centers and toxicologists have taken leadership roles nationwide. In regions where such leadership existed, preparedness levels are strong and collaborations resulted in the development of valuable response plans and training, including the Advanced Hazardous Life Support (AHLS) and Basic Disaster Life Support (BDLS) courses. Early success notwithstanding, experts suggest that current national preparedness has improved slightly from "1" (9/11) to "3" out of "10". Increasingly it has become evident that the nuclear threat, including radiation terrorism, is significant, against which the US remains inadequately prepared. Arguably the nuclear threat-whether accidental or planned-remains our highest consequence vulnerability, and we must rapidly improve our readiness across disciplines. Special populations including the elderly and children remain marginalized in preparedness protocols. Local vulnerabilities including chemical manufacturing and transportation--not just a risk for terrorism but industrial accidents--continue unabated. Our early success is not an endpoint; much work remains and time is fleeting. This report examines vulnerabilities that must be addressed to enhance preparedness.
Gamma hydroxybutyrate (GHB) is widey used as a sexual enhancement drug, a euphoriant, muscle building agent, a sleep aid, a weight loss agent, and as a date rapeagent. Precursor ingredients such as gammabutyrolactone (GBL) and GHB recipes are available, especially via the Internet. This is a report of an organic inkjet cleaner containing a GHB precursor 1,4-butanediol and butylenegycol. A 26-y-o male fell unconscious during work being unresponsive, with constricted pupils, and convulsing, he did not respond to naloxone. A bottle labeled "Hurricane" was found in his pocket. Five h later the patient awoke and was subsequently discharged with all vitals normal. The patient had recently purchased "Hurricane" as a sleep aid and to treat his panic attacks. It is an organic product with active ingredients similar to ink jet cleaner, the key ingredient being 1,4butanediol, which is metabolized to GHB. In spite of legislative changes restricting GHB, the precursors remain available and continue a public health threat.
Atypical antipsychotics are less likely to cause hyperprolactinemia-related side effects, such as infertility; hence it is predicted that more women taking antipsychotic medications will be able to become pregnant as the use of atypical antipsychotics increases. To compare the use of conventional and atypical antipsychotics, we conducted a retrospective review of the Motherisk Program clinic schedule from 1989 to 2001 comparing the proportion of appointments made for conventional and atypical antipsychotics. In 1989, 2.7% of all appointments were about the use of antipsychotic medication. In 2001, 7.4% of appointments were regarding antipsychotic drug use. This 170% increase was due to an increase in appointments for atypical antipsychotics as the number of appointments for conventional antipsychotics remained relatively constant over the 12-y period. Since the introduction of atypical antipsychotics, more women requiring antipsychotic drug therapy have been planning or becoming pregnant. This increase may have substantial public health implications.
Accidental hydrofluoric acid (HF) splashes often occur in industrial settings. HF easily penetrates into tissues by initial acid action allowing fluoride ions to penetrate deep, chelating calcium and magnesium. Resultant hypocalcemia and hypomagnesemia can be fatal. This report describes the utilization of Hexafluorine(R) - a hypertonic, amphoteric, chelating decontamination solution - in workplaces where water decontamination followed by calcium gluconate inunction failed to prevent HF burns and systemic toxicity. Between 1998 and 1999, 16 cases of ocular and dermal HF splashes with either 70% HF or 6% HF/15% nitric acid (HNO3) were decontaminated with Hexafluorine(R) at the worksite. HF burns did not develop and medical treatment other than initial decontamination was not required in 12/16 (75%). In 7/16 (44%) cases, lost work time corresponded to duration of hospital observation (mean <1 d).
An education program was implemented at a regional poison center to increase use of a new nationwide 800 number (800/222-1222) in counties in our region that had low rates of utilization. We identified 10 counties with the lowest utilization rates and provided textbook covers to the elementary and secondary schools in these areas. The covers contained the poison help logo and information about what to do if a poisoning occurs. Changes in utilization rate for these counties were compared to similar counties over the course of a year. Utilization rates increased in both sets of counties over the study period, but there was no significant difference (p = 0.84) between the 2 groups. Use of textbook covers to increase awareness and utilization made little impact beyond our normal efforts and was not cost-effective.
A 65-y-old man ingested about 600 mL of an alkaline detergent (pH 11.7) containing 3.3% monoethanolamine (MEA). After vomiting with choking several times, he presented to the emergency center with asthma-like symptoms 95 min after ingestion. Despite treatment with bronchodilators, steroids, and epinephrine, respiratory dysfunction progressed to acute respiratory distress syndrome resulting in death on the 4th hospital day. This is the first report of serious acute oral ingestion of an MEA-containing product; MEA aspirated into the respiratory tract may cause not only bronchial asthma symptoms, but may also severely injure the lung parenchyma.
Household adhesive ingestions are considered relatively non-toxic. Gorilla Glue(TM) is a household glue containing a urethane polymer and a polymeric isocyanate I liquid compound available in container sizes of 2 to 36 oz, and when applied with expand to 3-4 times its original volume. We report the ingestion of Gorilla Glue(TM) by 2 dogs that caused obstructive masses requiring surgical intervention. Dogs with a history of Gorilla Glue(TM) ingestion should be monitored closed by their owners and a veterinary referral made if signs of gastrointestinal distress develop.
This study determined the spectrum of deaths due to acute agrochemical poisoning in Turkey. Data was obtained from all autopsy reports performed between 1997 and 2001, compiled by the Institute of Forensic Medicine (which is a department of the Ministry of Justice), and evaluated retrospectively. There were 3990 deaths by intoxication of one form or another. Acute agrochemical/pesticide poisoning caused 843 deaths. Almost half were under 30 yo; 55% were female and 45% were male. Of 205 deaths whose manner of death was determined, 153 (75%) were suicide; the most common substance used was insecticide followed by sulfur, rodenticides, and herbicides. The pattern appeared consistent from 1997 to 2001 with no decline in the number of cases, despite the government having taken measures to educate the public and reduce pesticide use by offering alternates to control pests and insects.
We defined patient demographics, type of the poisoning, distribution according to month, route and reason for exposure, mortality causes and rates from 682 poisonings admitted to University Hospital in Kayseri, Turkey to evaluate whether they follow the pattern of other countries. Poisoning were drugs (54.5 %), inhalational poisonings including carbon monoxide (13.7%), food (12.4%), alcohol (7%), pesticides (5.4 %) and corrosives (2.1%). In drug ingestions, psychoactive drugs most common: psychoactive, analgesic, and anti-inflammatory drugs were most frequent agents in multiple drug poisonings. Drugs were the most used poison while pesticides, mushrooms, methanol and carbon monoxide caused more deaths. The mortality rate was 2%.
To determine the various factors involved in poisoning deaths, a 10-y retrospective review of 335 cases were carried out. There was an increasing trend in number of poisoning deaths from 1993-94 to 1999-2000, followed by a decline trend the last 2y (2001-02). Ninety-one percent of the deaths were due to self-poisoning, with 77.6% of the fatalities due to insecticide consumption. Most cases occurred during winter and in the victim's rural home. Amongst all the poisoning deaths, 249 were males and 86 were females, most in the of 20-29y age group. Suggestions have been made for the prevention of insecticide poisoning.
