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Category: Original Research

Validation of a Pediatric Cognitive Assessment Tool to Advance Knowledge on Children’s Cognitive Development, Health Risk Factors, and Health-promoting Interventions in Sub-Saharan Regions

Innov Clin Neurosci. 2025;22(10–12):33–51. by Franco Di Cesare, MD; Cristiana Di Carlo, MPhil; and Leonardo Di Cesare, MD All authors are with Leoben Research Aurora in San Vincenzo Valle Roveto

Adaptation, Translation, and Validation of the Perceived Parenting Style Scale in Pakistan Using ITC Protocol

Innov Clin Neurosci. 2025;22(10–12):72–77. by Anam Shahid, PhD; Alia Asmat, PhD; and Sunny Singh, MD Dr. Shahid and Dr. Singh are with the Nova Scotia Health Authority in Sydney, Nova

Burnout and Ethical Awareness in Mental Health Professionals: A Correlational Study

Innov Clin Neurosci. 2025;22(7–9):24–27. by Muqadas Fatima, MS, and Uzma Ilyas, PhD Ms. Fatima is serving as Lecturer at National University of Modern Languages (NUML) in Lahore, Pakistan. Dr. Ilyas

Cognitive Difficulty Concentrating, Remembering, or Making Decisions According to Chronic Medical Conditions and Cannabis Use Among US Adults in 2022

Innov Clin Neurosci. 2025;22(7–9):32–39. by Ray M. Merrill, PhD, MPH Dr. Merrill is with the Department of Public Health in the College of Life Sciences at Brigham Young University in

Validation of a Clinical Decision Support Tool for Quantifying Risk of Torsades de Pointes in a Psychiatric Inpatient Population

by Samara White, PharmD; Tammie Lee Demler, PharmD, MBA, BCGP, BCPP; and Eileen Trigoboff, RN, PMHCNS-BC, DNS, DABFN Drs. White and Demler are with The New York State Office of

Measurement-based Care Training Curriculum in Psychiatry Residency Programs: Four-year Implementation Experience and Future Directions

by Ahmed Aboraya, MD, DrPH; Daniel Elswick, MD; James Berry, DO; Dilip Chandran, MD; Cheryl Hill, MD; Wanhong Zheng, MD; Jeremy D. Hustead, MD; Dorothy Van Oppen, MD; Vishal Patel,

Sociodemographic Factors and Consanguinity in Intellectual Disability: A Pilot Study

by Dr. Yousra Benmakhlouf, PhD; Dr. Achraf Laghmich, PhD*; Kaoutar Ben Makhlouf, PhD*; Prof. Amina Barakat, PhD; Prof. Naima Ghailani Nourouti, PhD; and Prof. Mohcine Bennani Mechita, PhD All authors

Patient Challenges in Utilization of Methadone to Treat Opioid Use Disorder and Perspectives on a Solution for Improved Security and Convenience in Take-home Dosing

by Eric Morse, MD; Graeme Christianson, BSE; Melissa Olivadoti, PhD; and John Timberlake, MBA Dr. Morse is with Carolina Performance in Raleigh, North Carolina and Morse Clinics in Raleigh, North

Outcome of Ischemic Stroke at Six Months with Neuroglobin as a Marker

by Yetty Ramli, MD, SpN(K); Fadhlan Rusdi, MD, SpN; Mohammad Kurniawan, MD, SpN(K); Mohamad Sadikin, MD, DSc; and Florencia Evelyn, MD Drs. Ramli, Rusdi, Kurniawan, and Evelyn are with the

Analysis of Levels of Vitamin D, Beta-Amyloid 42, Indoxyl Sulfate, and Serum Parathyroid Hormone in Hemodialysis Patients with Cognitive Impairment

by Prof. Yuliarni Syafrita, Sp.N(K); Harnavi Harun, Sp.PD-KGH, FINASIM; Restu Susanti, Sp.S(K) M. Biomed; and Syarif Indra, Sp.N(K) Prof. Syafrita and Drs. Susanti Indra are with the Department of Neurology,

Study of Clinical Characteristics of Intellectual Disability in Morocco

by Houda Bekkari , PhD; Dr. Yousra Benmakhlouf, PhD; Prof. Naima Ghailani Nourouti, PhD; Prof. Amina Barakat, PhD; and Prof. Mohcine Bennani Mechita, PhD All authors are with Intelligent Automation

The Impact of High-density Lipoprotein Cholesterol (HDL-C) Levels and Risk of Movement Disorders in Patients Taking Antipsychotics

by CAROLYN O’DONNELL, PharmD; TAMMIE LEE DEMLER, BS, PharmD, MBA, BCGP, BCPP; EILEEN TRIGOBOFF, RN, PMHCNS-BC, DNS, DABFN; and CLAUDIA LEE, MD Dr. O’Donnell is with Edward Hines Jr. Veterans

Impact of COVID-19 Pandemic on Patients with Serious Mental Illness (SMI) and Nonpsychiatric Control Subjects in Clinical Trials

by Maria Fe Garcia-Rada, MPS, and Robert E. Litman, MD Ms. Fe Garcia-Rada and Dr. Litman are with CenExel CBH Health in Gaithersburg, Maryland. Dr. Litman is additionally with Georgetown

Outpatient Pharmacogenomic Screenings to Prevent Addiction, Overdose, and Suicide

by Atmaram Yarlagadda, MD; Kevin Swift, PhD; Nabarun Chakraborty, MS, MBA; Rasha Hammamieh, PhD; Amina Abubakar, PharmD; Marianna Wilbur, PharmD; and Anita H. Clayton, MD Dr. Yarlagadda is Installation Director

Impact of COVID-19 on the Mental Health of Psychiatric Inpatients

by Samara White, PharmD; Tammie Lee Demler, BS, PharmD, MBA, BCGP, BCPP; Eileen Trigoboff, PMHCNS-BC, DNS, DABFN; Lucy Keers, PharmD; and Chloe Matecki, PharmD All authors are with Department of

Impact of the Medication Shortages on Psychiatric Patients: Exploring the Consequences of Lorazepam Injection Scarcity

by Yael Marks, BS, PharmD; Tammie Lee Demler, BS, PharmD, MBA, BCGP, BCPP; and Chloe Matecki, PharmD All authors are with Department of Pharmacy Practice, State University of New York

WORDS: A New Verbal Memory Test to Evaluate Cognitive Health in a Zambian School-aged Population

by Franco Di Cesare, MD; Giulia Piccinini, MD; Cristiana Di Carlo, MPhil; and Leonardo Di Cesare, MD Drs. F. Di Cesare, Di Carlo, and L. Di Cesare are with Leoben

Innovative Technologies in CNS Trials: Promises and Pitfalls for Recruitment, Retention, and Representativeness

by Jacqueline Lutz, PhD; Abhishek Pratap, PhD; Eric J. Lenze, MD; Durga Bestha, MD; Jessica M. Lipschitz, PhD; Stella Karantzoulis, PhD; Uma Vaidyanathan, PhD; Jessica Robin, PhD; William Horan, PhD;

Exploring the Impact of COVID-19 Vaccination on Patients Taking Clozapine

by Tammie Lee Demler, PharmD, MBA, BCGP, BCPP; and Carolyn O’Donnell, PharmD, PGY-2 Drs. Demler and O’Donnell are with the New York State Office of Mental Health at Buffalo Psychiatric

WAVES: A Novel Test to Evaluate Visuospatial Construction Ability in a School-aged Population

by Franco Di Cesare, MD; Cristiana Di Carlo, MSc; and Leonardo Di Cesare, MD Drs. F. Di Cesare and Di Carlo are with Leoben Research srl in Rome, Italy. Dr.

Development of a Symbol Cancellation Test to Evaluate Attention in a School-aged Zambian Population

by Franco Di Cesare, MD; Cristiana Di Carlo, MSc; and Leonardo Di Cesare, MD Drs. F. Di Cesare and Di Carlo are with Leoben Research srl in Rome, Italy. Dr.

Executive Functioning in Children and Adolescents with ADHD and Disruptive Behavior Disorders

by Rosa Elena Ulloa Flores, MD, PhD; Ricardo Díaz Sánchez, BS; Francisco R. de la Peña, MD, MS; Marcos F. Rosetti Sciutto, PhD; Lino Palacios Cruz, MD, PhD; and Pablo

Olfactory Dysfunction in Incidental Lewy Body Disease and Parkinson’s Disease: An Update

by Shemonti Hasan, MD; Charles H. Adler, MD, PhD; Nan Zhang, MS; Geidy E. Serrano, PhD; Lucia I. Sue, BS; Holly A. Shill, MD; Shyamal H. Mehta, MD, PhD; Thomas

Impact of COVID-19 Pandemic on Psychiatric Patients at Clinical Trial Sites

by Maria Fe Garcia-Rada, MPS, and Robert E. Litman, MD Ms. Garcia-Rada and Dr. Litman are with CenExel CBH Health in Gaithersburg, Maryland. Dr. Litman is with Georgetown University Medical

Pre-, Peri-, and Neonatal Factors Associated with Autism Spectrum Disorder: Results of a Lebanese Case-control Study

by Aline Hajj, PharmD, PhD; Souheil Hallit, PharmD, MSc, MPH, PhD; Rouba El-Khatib, PharmD; Sandra Abi Haidar, PharmD; Fabienne Hajj Moussa Lteif, MSc; Layal Hajj, MSc; Maguy Moudawar, MSc; and

Quantitative Characterization of the Smoothness of Extended-release Methylphenidate Pharmacokinetic Profiles

by Michelle D. Po, PhD; Roberto Gomeni, PhD, HDR, FCP; and Bev Incledon, PhD Dr. Po is with Highland Therapeutics Inc. in Toronto, Ontario, Canada. Dr. Gomeni is with PharmacoMetrica

EcoMeditation Modifies Brain Resting State Network Activity

by Peta Stapleton, PhD; Dawson Church, PhD; Oliver Baumann, PhD; and Debbie Sabot, BA, Grad Dip Psych Drs. Stapleton and Baumann and Ms. Sabot are with the School of Psychology,

Abnormality of Contingent Negative Variation Correlates with Parkinson’s Disease Severity

by Plamen Tzvetanov, MD, Phd, DSc, FRCP; Ivan Lisichkov, MD, PhD; Rossen T. Rousseff MD, PhD; Vishwajit Hegde, MD, FRCP; and Sergey Kostadinov, MD, PhD Prof. Tzvetanov is with the

SIBAT—A Computerized Assessment Tool for Suicide Ideation and Behavior: Development and Psychometric Properties

by Larry Alphs, MD, PhD; Dong-Jing Fu, MD, PhD; David Williamson, PhD; Carol Jamieson, BSc, FIBMS; John Greist, MD; Magdalena Harrington, PhD; Jean-Pierre Lindenmayer, MD; Cheryl McCullumsmith, MD, PhD; David

Correlation Between CD133+ Stem Cells and Clinical Improvement in Patients with Autism Spectrum Disorders Treated with Intrathecal Bone Marrow-derived Mononuclear Cells

by Laura Villarreal-Martinez, MD; Laura Elia MartÍnez-Garza, MD; Iram Pablo Rodriguez-Sanchez, MD; Neri Alvarez-Villalobos, MD; Fernando Guzman-Gallardo, MD; Sulia Pope-Salazar, MD; Cynthia Salinas-Silva, MD; Maria Guadalupe Cepeda-Cepeda, MD; Alejandra Garza-Bedolla,

Selective Serotonin Reuptake Inhibitors (SSRIs) and Their Effect on Patient Aggression in Adult Patients in a State Psychiatric Facility: A Retrospective Analysis

by Carolyn O’Donnell, PharmD; Tammie Lee Demler, PharmD, MBA, BCGP, BCPP; and Eileen Trigoboff, RN, PMHCNS-BC, DNS, DABFN; Drs. O’Donnell, Demler, and Trigoboff are with the State University of New

Development of a Cognitive Ability Assessment Tool for a Pediatric School-aged Population

by Franco Di Cesare, MD; Leonardo Di Cesare; and Cristiana Di Carlo, MSc Dr. F. Di Cesare, Mr. L. Di Cesare, and Ms. Di Carlo are with Leoben Research srl

Trends of Adverse Drug Reaction Reports in a Hospitalized Psychiatric Population: Exploring Prescriber Discontinuations as Potential Unreported Adverse Drug Events

by Tammie Lee Demler, BS, PharmD, MBA, BCGP, BCPP, and Charisse Chehovich, PharmD Drs. Demler and Chehovich are with the Buffalo Psychiatric Center, New York State Office of Mental Health,

Energy Drink Use in Adolescents With and Without ADHD: Trends and Influences

by Chiranjir Narine, MD; Jennifer Weller, PhD; and Kathleen Mathieson, PhD, CIP Dr. Narine is the Medical Director of Valleywise Behavioral Health/District Medical Group in Phoenix, Arizona. Dr. Weller is

Intellectual Disability in Morocco: A Pilot Study

by Yousra BENMAKHLOUF, PhD; Zeineb ZIAN, PhD; Kaoutar BEN MAKHLOUF; Naima GHAILANI NOUROUTI, PR; Amina BARAKAT, PR; and Mohcine BENNANI MECHITA PR Drs. Benmakhlouf, Zian, Ghailani Nourouti, Barakat, and Bennani

Pilot Mental Health Survey, Nepal: Lessons Learned for Survey Design and Instrumentation

by Sushma Dahal, MPH; Meghnath Dhimal, PhD; Sagun Ballav Pant, MD; Pawan Sharma, MD; Kedar Marahatta, MD; Nagendra Luitel, MA; Suraj Shakya, PhD; Sweta Labh, BSc Nursing; Saroj Prasad Ojha,

The Depression Inventory Development Scale: Assessment of Psychometric Properties Using Classical and Modern Measurement Theory in a CAN-BIND Trial

by Anthony L. Vaccarino, PhD; Amir H. Kalali, MD; Pierre Blier, MD, PhD; Susan Gilbert Evans, MSc; Nina Engelhardt, PhD; Jane A. Foster, PhD; Benicio N. Frey, MD, PhD; John

Layperson/Plain Language Summaries: Can Sponsors, CROs, and Sites Deliver in 2020?

by Charles S. Wilcox, PhD, MPA, MBA; Leslie Franceschi, BA; and ADAM SIMMONS, MPH Dr. Wilcox is Chief Executive Officer at Praxis Research Consulting in Newport Beach, California. Ms. Franceschi

Psychiatric Comorbidities in Adult Attention-deficit/Hyperactivity Disorder: Prevalence and Patterns in the Routine Clinical Setting

by Takashi Ohnishi, MD, PhD; Hisanori Kobayashi, PhD; Tsutomu Yajima, MS; Takeshi Koyama, MS; and Kenichi Noguchi, PhD Drs. Ohnishi, Kobayashi, and Noguchi are with the Medical Affairs Division, Mr.

The Effect of Acutely Administered Propofol on Forced Swim Test Outcomes in Mice

by David G. Daniel, MD; Noah G. Daniel; Donald T. Daniel; Laura Copeland Flynn, MS; and Michael H. Allen, MD Dr. Daniel is with Bioniche Global Development, LLC in McLean,

Correlation Between the Movement Disorder Society’s Unified Parkinson’s Disease Rating Scale and Nonmotor Scales in Patients with Parkinson’s Disease

by Erika D. Driver-Dunckley, MD; Nan Zhang, MS; Holly A. Shill, MD; Shyamal H. Mehta, MD, PhD; Christine M. Belden, PsyD; Edward Y. Zamrini, MD; Kathryn Davis; Thomas G. Beach,

Treatment of Functional Gait Abnormality in a Rehabilitation Setting: Emphasizing the Physical Interventions for Treating the Whole Child

by Catherine Butz, PhD; Cindy Iske, MS, OTR/L; Natalie Truba, PhD; and Kristen Trott, PhD Drs. Butz, Truba, and Trott are with the Psychology Department, and Ms. Iske is Program

Increased Levels of Protein-methionine Sulfoxide in Plasma Correlate with a Shift from a Mild Cognitive Impairment to an Alzheimer’s Disease Stage

by Yue Deng, MSc; Brianna M. Marsh, BSc student; and Jackob Moskovitz, PhD Mr. Deng, Ms. Marsh, and Dr. Moskovitz are with the Department of Pharmacology and Toxicology at the

Exploring the Effectiveness of Team-based Enablement Interventions to Improve Antibiotic Prescribing within a Psychiatric Hospital

by Emily E. Leppien, PharmD, BCPS; Tammie Lee Demler, BS, PharmD, MBA, BCGP, BCPP; and Eileen Trigoboff, RN, PMHCNS-BC, DNS, DABFN Dr. Leppien is with the Binghamton University School of

Therapeutic Potential of Ponesimod Alone and in Combination with Dimethyl Fumarate in Experimental Models of Multiple Sclerosis

by Laetitia Pouzol, MSc, PharmD; Luca Piali, PhD; Claude CA Bernard, PhD; Marianne M. Martinic, PhD; Beat Steiner, PhD; and Martine Clozel, MD Drs. Pouzol and Clozel were with Actelion

Exploring the Potential Psychiatric Implications of Astronomical Phenomena

by Tammie Lee Demler, BS, PharmD, MBA, BCGP, BCPP; Michaela Camille Lysogorski, PharmD; and Eileen Trigoboff, RN, RMHCNS-BC, DNS, DABFN Drs. Demler and Trigoboff are with the University of Buffalo,

Validation of an Equation Model to Predict Intracranial Pressure in Clinical Studies

by Niro Kasahara, MD; Mateus L. Matuoka, MD; Katia S. Santos, MD; Natasha F.S. Cruz, MD; Alvaro R. Martins, MD; and Stanley Nigro, MD Drs. Kasahara, Matuoka, Santos, and Cruz

Does Vitamin D Deficiency Contribute to Cognitive Dysfunction in Patients with Systemic Lupus Erythematosus?

by Hoda A. Hussein, MD; Lamiaa I. Daker, MD; Nermeen A. Fouad, MD; Azza Elamir, MD; and Shereen R. Mohamed, MD Dr. Hussein is with the Internal Medicine Department, Dr.

Atypical Neuroleptic Malignant Syndrome Precipitated By Clozapine And Quetiapine Overdose: A Diagnostic Challenge

By David Choon Liang Teo, MBBS, MRC Psych (UK), FAMS (Psychiatry); Hon Khuan Wong, MBBS; Sheng Neng Tan, MBBS, MMED (Psychiatry), FAMS (Psychiatry) Drs. Teo, Wong and Tan are with

Implementation of the Electronic Columbia-Suicide Severity Rating Scale (eC-SSRS™) Across Four Phase IIIB Clinical Trials in HIV-Infected Individuals (ARIA, STRIIVING, DAWNING and INSPIRING)

By Clare Brennan, DPT, MSPH; Hannah Whillis, MS; Choy Man, BS; Brian Wynne, MD; Vani Vannappagari, MBBS, MPH, PhD Dr. Brennan and and Ms. Man are with Clinical Development and

Effects of Lisdexamfetamine Dimesylate on Functional Impairment Measured on the Sheehan Disability Scale in Adults With Moderate-to-severe Binge Eating Disorder: Results from Two Randomized, Placebo-controlled Trials

by David V. Sheehan, MD, MBA; Maria Gasior, MD, PhD; Susan L. McElroy, MD; Jana Radewonuk, MSc; Barry K. Herman, MD, MMM; and James Hudson, MD, ScD Dr. Sheehan is

Combination Phentermine–Topiramate Extended Release for the Treatment of Binge Eating Disorder: An Open-Label, Prospective Study

By Anna I. Guerdjikova, PhD, LISW; Stephanie Williams, MS; Thomas J. Blom, MS; Nicole Mori, CNP; and Susan L. McElroy, MD Drs. Guerdjikova and McElroy and Ms. Mori are with

Audio Recording for Independent Confirmation of Clinical Assessments in Generalized Anxiety Disorder

by Steven D. Targum, MD; Christopher Murphy, PhD; Jibran Khan, BA; Laura Zumpano, BA; Mark Whitlock, PhD; Arthur A. Simen, MD, PhD; and Brendon Binneman, MD† Drs. Targum and Murphy

Lower-extremity Dynamometry as a Novel Outcome Measure in a Double-blind, Placebo-controlled, Feasibility Trial of Intravenous Immunoglobulin (IVIG) for HIV-associated Myelopathy

by Jessica Robinson-Papp, MD, MS; Mary Catherine George, MM, PhD; Alexandra Nmashie, MD; Donald Weisz, PhD; and David M. Simpson, MD Drs. Robinson-Papp, George, Nmashie and Simpson are with the

Interactive Voice Response and Text-based Self-report Versions of the Electronic Columbia-Suicide Severity Rating Scale Are Equivalent

by Chad Gwaltney, PhD; James C Mundt, PhD; John H. Greist, MD; Jean Paty, PhD; and Brian Tiplady, PhD Dr. Gwaltney is with Gwaltney Consulting, Westerly, Rhode Island (with ERT

Performance, Reliability, Usability, and Safety of the ID-Cap System for Ingestion Event Monitoring in Healthy Volunteers: A Pilot Study

by Glen P. Flores, PhD; Brian Peace, BS; Tony C. Carnes, PhD; Susan L. Baumgartner, PharmD, MBA; D. Eric Buffkin, Jr., MBA; Neil R. Euliano, PhD; and Larry N. Smith,

Assessment of Cognitive and Neurologic Recovery in Ischemic Stroke Drug Trials: Results from a Randomized, Double-blind, Placebo-controlled Study

by Franco Di Cesare, MD; Jessica Mancuso, PhD; Brian Silver, MD; and Peter T. Loudon, PhD Dr. Di Cesare is with Leoben Research Limited in Glasgow, UK; Dr. Mancuso is

Inter-rater Reliability Assessment of ASPECT-R (A Study Pragmatic-Explanatory Characterization Tool-Rating)

by Cynthia A. Bossie, PhD; Larry D. Alphs, MD, PhD; David Williamson, PhD; Lian Mao, PhD; Clennon Kurut, BS; and the ASPECT-R Rater Team Drs. Bossie, Alphs, and Williamson are

Erectile Dysfunction in Individuals with Neurologic Disability: A Hospital-based, Cross-sectional Study

by Rocco Salvatore Calabrò, MD, PhD; Giuseppe Gervasi, MD, PhD; Antonino Naro, MD, PhD; Rosaria De Luca, PhD; Michelangelo Marullo, MD; and Placido Bramanti, MD Drs. Calabró, Naro, de Luca,

Letter to the editor: Resident and Patient Responses to the Institution of Required Narcotic Agreements in an Internal Medicine Outpatient Clinic

Dear Editor: An estimated 75 million Americans experience nonmalignant chronic pain,[1] and oftentimes the responsibility for management falls to the primary care provider. Therefore, pain management is an increasingly important

Novel Therapeutic Approach by Nicotine in Experimental Model of Multiple Sclerosis

by Fatemeh Naddafi, MSc; Mohsen Reza Haidari, PhD; Gholamreza Azizi, MSc; Reza Sedaghat, PhD; and Abbas Mirshafiey, PhD Ms. Naddafi is from Department of Cellular and Molecular Biology, Kish International

CNS Sites Cooperate to Detect Duplicate Subjects with a Clinical Trial Subject Registry

by Thomas M. Shiovitz, MD; Charles S. Wilcox, PhD, MPA, MBA; Lilit Gevorgyan, BS; and Adnan Shawkat, BA Dr. Shiovitz is from CTSdatabase, LLC, in Beverly Hills, California and California

A Urinalysis-based Comparative Study of Treatment Adherence on Buprenorphine and Buprenorphine/Naloxone Combination Used as Opioid Substitution Therapy

by Yatan Pal Singh Balhara, MD, DNB (Psychiatry), MNAMS, and Raka Jain, PhD, CChem FRSC Dr. Balhara is Assistant Professor of Psychiatry, National Drug Dependence Treatment Center (NDDTC), All India

Attention Deficit Hyperactivity Disorder Subtypes and Symptom Response in Adults Treated With Lisdexamfetamine Dimesylate

by Greg Mattingly, MD; Richard Weisler, MD; Bryan Dirks, MD; Thomas Babcock, DO; Ben Adeyi, MS; Brian Scheckner, PharmD; and Robert Lasser, MD Dr. Mattingly is from Washington University School

Can Tactile Sensory Processing Differentiate Between Children with Autistic Disorder and Asperger’s Disorder?

by Ahmad Ghanizadeh, MD Dr. Ghanizadeh is from the Department of Psychiatry, Research Center for Psychiatry and Behavioral Sciences, Shiraz University of Medical Sciences, Hafez Hospital, Shiraz, Iran. Innov Clin

False-Positive Urine Screening for Benzodiazepines: An Association with Sertraline? A Two-year Retrospective Chart Analysis

by Kevin M. Nasky, DO; George L. Cowan, MD, MS; and Douglas R. Knittel, MD Dr. Nasky is Staff Psychiatrist, Department of Psychiatry, Naval Medical Center, Portsmouth; Dr. Cowan is