Deer Lodge Centre

ABSTRACT Background: Potentially morally injurious experiences (PMIEs) are common during military service. However, it is unclear to what extent PMIEs are related to well-established adverse mental health outcomes. Objective: The objective of this study was to use a population-based survey to determine the associations between moral injury endorsement and the presence of past-year mental health disorders in Canadian Armed Forces (CAF) personnel and Veterans. Methods: Data were obtained from the 2018 Canadian Armed Forces Members and Veterans Mental Health Follow-up Survey (CAFVMHS). With a sample of 2,941 respondents, the weighted survey sample represented 18,120 active duty and 34,380 released CAF personnel. Multiple logistic regressions were used to assess the associations between sociodemographic characteristics (e.g. sex), military factors (e.g. rank), moral injury (using the Moral Injury Events Scale [MIES]) and the presence of specific mental health disorders (major depressive episode, generalized anxiety disorder, panic disorder, social anxiety disorder, PTSD, and suicidality). Results: While adjusting for selected sociodemographic and military factors, the odds of experiencing any past-year mental health disorder were 1.97 times greater (95% CI = 1.94–2.01) for each one-unit increase in total MIES score. Specifically, PTSD had 1.91 times greater odds (95% CI = 1.87–1.96) of being endorsed for every unit increase in MIES total score, while odds of past-year panic disorder or social anxiety were each 1.86 times greater (95% CI = 1.82–1.90) for every unit increase in total MIES score. All findings reported were statistically significant (p < .001). Conclusion: These findings emphasize that PMIEs are robustly associated with the presence of adverse mental health outcomes among Canadian military personnel. The results of this project further underscore the necessity of addressing moral injury alongside other mental health concerns within the CAF.

Although an essential component of best practice, wheelchair skills training is often inadequate; occupational therapy practitioners' professional preparation is a contributing factor. To assess the effectiveness of a boot camp on capacity and self-efficacy in wheelchair skills and self-efficacy in clinical practice, retention of improvements, and effective boot-camp attributes. Concurrent, embedded, mixed-methods cohort design that used blinded, repeated-measures quantitative evaluation with 4-mo follow-up and directed content analysis of a qualitative questionnaire. University entry-to-practice program. Convenience sample (N = 42) of final-year students. A 4-hr boot camp with demonstration and supervised practice. Content incorporated skill performance, training and motor-learning strategies, and safe supervision. Skill performance capacity (Wheelchair Skills Test-Questionnaire), self-efficacy with manual wheelchair use (Wheelchair Use Confidence Scale), confidence in provision of manual wheelchair training services (Self-Efficacy in Assessing, Training, and Spotting test), and a boot-camp experience questionnaire. Within-subjects analysis of variance revealed significant improvements on all measures (p < .001) with large effect sizes (ηp² = .68-.88). All measures except skill capacity demonstrated retention; skill capacity decreased 5.3% (95% confidence interval [2.0, 8.5]) but was significantly higher than baseline. Three themes influenced practice confidence: knowledge acquisition, experiential learning, and client empathy. Results confirm improved wheelchair self-efficacy, capacity, and self-efficacy with clinical intervention skills. Retention of outcomes suggests the potential impact on future practice. Experiential learning supports performance component acquisition and imparts empathy of client experience, which may improve occupational therapy practitioners' perceptions of client potential. A 4-hr experiential boot camp can increase students' capacity and confidence to deliver wheelchair skills training to future clients. Experiential learning increased students' appreciation for clients' experience and expectation of client potential.

KEY POINTS Psychosis developed in a 70-year-old woman with a 12-year history of Parkinson disease after she ingested nabilone, a synthetic cannabinoid. The patient had chronic and painful dystonia in both feet that occurred as her medications were wearing off; this was resistant to management with

This article describes the case of a 69-year-old man with a long history of swallowing difficulties and a past diagnosis of obsessive-compulsive disorder. He was seen for treatment by a speech-language pathologist and a clinical psychologist. Prior to treatment, he ate only one type of sweet dessert and some pureed foods, at restricted times of the day, and without others present. Treatment focused on increasing variety in his diet, increasing bolus size, reducing ritualistic and safety behaviors, and eating in social situations. Treatment methods included surface electromyographic biofeedback and systematic desensitization. After 19 months of treatment (49 sessions), the patient was able to eat a variety of soft/ground foods. He gained weight and was able to eat in social situations. At post-treatment, 8-month and 48-month follow-up, he reported being satisfied with his progress and did not wish to pursue further goals involving eating solid foods or increasing bolus size of liquids.

While surgical arthrodesis is the treatment of choice for osteoarthritis of the proximal interphalangeal joint, some clients are unable to pursue surgery due to costs. A more economical technique was sought using intra-articular ethyl alcohol injections to facilitate ankylosis. To describe the technique and outcome of intra-articular ethyl alcohol injections for facilitated ankylosis of proximal interphalangeal joints with osteoarthritis. As a retrospective case series, the medical records (2006-2012) of clinical cases diagnosed with proximal interphalangeal joint osteoarthritis treated with intra-articular ethyl alcohol injections were reviewed. Cases with follow-up of at least 6 months were included. Technique and outcome were determined. Evaluation of outcome was assessed using return to previous performance or intended use and owner satisfaction as the indicators of success. Soundness and level of work are also reported. Thirty-four horses were included in the study. At the time of follow-up, 17 horses (50%) were sound, while 13 horses (38%) were improved but not sound. One horse's lameness was unchanged, and 3 horses were lost to follow-up. The median time until horses became sound or returned to work was 8 months. Six horses had complications, 4 of which were mild and transient. The use of intra-articular ethyl alcohol in the proximal interphalangeal joint in horses affected by osteoarthritis appears to be a viable method for facilitated ankylosis if surgical management is not an option.

At Deer Lodge Centre, oral care practice for adult dependent patients often included the use of sponge swabs and liquid mouth rinse, but the facility had no formal policy outlining best practice. The authors sought to develop such a policy by answering two main questions: Are sponge swabs effective in cleaning the oral cavity? What oral care is required for individuals with dysphagia and those who depend on others for oral care? After a review of the literature for pertinent guidance, a new protocol for oral care, based on tooth brushing and use of antibacterial gel, was implemented for one care unit. Patients showed improvements in oral health, specifically reductions in tartar, swollen and bleeding gums, ulcerations, debris and severe halitosis. Staff members were initially resistant to change, but resistance declined as they witnessed the benefits of tooth brushing. The use of sponge swabs also declined. This intervention confirmed that tooth brushing is appropriate as the gold standard of good oral care and showed that sponge swabs are ineffective for removing plaque. These principles have become the foundation of oral care policies and care plans at this facility.

Nady el-Guebaly, MD, DPH, DPsych, FRCPC1; Jitender Sareen, MD, FRCPC2; Murray B Stein, MD, MPH, FRCPC3 Can J Psychiatry. 2010;55(11):709-714. The Prevalence of Prescriptions and Their Indications Benzodiazepines are reportedly the most frequently prescribed psychotropic medication. Among adults in the United States and Canada, 3% to 4% are using BDZs at any one time.1 About 100 million prescriptions are written per year. The European Study of the Epidemiology of Mental Disorders (commonly referred to as ESEMeD) investigated the use of ADs and BDZs in 2 1 425 respondents from 6 countries. In the nonhelp-seeking population, BDZs were used more commonly than ADs, while in the help-seeking population, with a 12-month prevalence of major depressive disorder or anxiety disorder, BDZs were used as commonly as ADs. In an Australian study/ 16% of the adults aged 65 years and older (n = 3970) had at least 1 BDZ prescription and the prescription prevalence increased with age. BDZs' sedative, hypnotic, and anxiolytic properties are used for various psychiatric and medical conditions including anxiety disorders, sleep disorders, seizure disorders, movement disorders, and muscle spasticity. They are used in anaesthesiology and for the symptomatic treatment of agitation associated with other psychiatric and neurological disorders including psychotic, mood, and cognitive disorders.4 In emergencies they are the preferred treatment of withdrawal from alcohol and sedative-hypnotics as well as agitation from stimulants. Tolerance to sedative effects usually develops among people receiving maintenance therapy with a stable dose of BDZs; by contrast, the memory-impairing effects can persist after several years of daily administration.5 Overdoses are almost never fatal unless occurring in combination with other sedative agents such as alcohol or opiates. The reinforcing effects of BDZs may not only be mediated through binding of the alpha 1 or lambda 2 subtypes of GABA receptors but also via an opioid mechanism. A partial mu receptor antagonist such as naltrexone may reduce anxiolytic and positive subjective effects of BDZs. This may explain the high level of co-occurrence of BDZs and opioid dependence. Of interest, BDZs are the only major class of drugs with abuse liability that decrease dopamine levels in the mesolimbic system.6 From Physiologic Dependence to Loss of Control The dose and duration of exposure to BDZs determines the development of physiological dependence. It is almost never seen in patients treated for less than 2 weeks but occurs in about 50% of patients treated daily for more than 4 months. Short- and long-acting BDZs produce comparable severity of withdrawal. The development of physiological dependence is reduced with intermittent, compared with continuous, exposure to BDZs. Among people exposed to BDZs, a small subset, likely among those who have abused other substances, will develop compulsive drug-seeking behaviour with loss of control and an inability to stop. The same may apply to people with a positive family history of drug or alcohol dependence, given that some of the risk may be hereditary.7 Most patients treated chronically with BDZs, who presumably may have physiological dependence, do not develop compulsive substance use,8 and some patients present with compulsive substance use without physiological dependence. The abuse potential of BDZs depends not only on the drug receptor selectivity but also on the characteristics of the individual and environmental circumstances. BDZs as a primary substance of abuse in people admitted for addiction treatment make up less than 1 % of all admissions. Most of these people report abuse of alcohol or opioids in addition to BDZs.9 The presence of another co-occurring psychiatric disorder (mood, anxiety, and Cluster C personality) occurs in up to 50% of these admissions. Among patients on methadone maintenance treatment, 40% to 50% abuse BDZs. …