Robert J. Dole VA Medical Center

BACKGROUND: Low health literacy is associated with higher health care utilization and costs; however, no large-scale studies have demonstrated this in the Veterans Health Administration (VHA). This research evaluated the association between veterans' health literacy and their subsequent VHA health care costs across a three-year period. METHODS: This retrospective study used a Generalized Linear Model to estimate the relative association between a patient's health literacy and VHA medical costs, adjusting for covariates. Secondary data sources included electronic health records and administrative data in the VHA (e.g., Medical and DCG SAS Datasets and DSS-National Data Extracts). Health literacy assessments and identifiers were electronically retrieved from the originating health system. Demographic and cost data were retrieved from the VHA centralized databases for the corresponding patients who had VHA use in all three years. RESULTS: In a study of 92,749 veterans with service utilization from 2007-2009, average per patient cost for those with inadequate and marginal health literacy was significantly higher ($31,581 [95 % CI: $30,186 - $32,975]; $23,508 [95 % CI: $22,749 - $24,268]) than adequate health literacy ($17,033 [95 % CI: $16,810 - $17,255]). Estimated three-year cost associated with veterans' with marginal and inadequate health literacy was $143 million dollars more than those with adequate health literacy. CONCLUSIONS: Analyses suggest when controlling for other person-level factors within the VHA integrated healthcare system, lower health literacy is a significant independent factor associated with increased health care utilization and costs. This study confirms the association of lower health literacy with higher medical service utilization and pharmacy costs for veterans enrolled in the VHA. Confirmation of higher costs of care associated with lower health literacy suggests that interventions might be designed to remediate health literacy needs and reduce expenditures. These analyses suggest 17.2 % (inadequate & marginal) of the Veterans in this population account for almost one-quarter (24 %) of VA medical and pharmacy cost for this 3-year period. Meeting the needs of those with marginal and inadequate health literacy could produce potential economic savings of approximately 8 % of total costs for this population.

SUMMARY Fifty parents of 36 consecutive children admitted to hospital with their first febrile convulsion were interviewed shortly after the event. Very few parents voluntarily said that they had thought their child was dying, but when asked specifically the majority said they had thought the child was dying or likely to die. This common fear should be kept in mind when discussing febrile convulsions with parents, who are unlikely to volunteer the information. RÉSUMÉ Les parents pensent habituellement que lew enfant va mourir, lorsqu'ils observent chez lui la premiére convulsion hyperthermique 50 parents de 36 enfants admis consécutivement à l'hôpital aprés une premiere crise convulsive hyperthermique ont été interrogés peu apres l'evenement. Trés peu de parents mentionerent spontanement qu'ils avaient pense que leur enfant allait mourir mais en réponse à une question précise la majorité des parents précisèrent qu'ils avaient effectivement pensé que leur enfant était mourant ou allait mourir. Cette crainte commune doit être gardee à l'esprit dans une discussion sur les convulsions fébriles avec des parents qui cachent plus volontiers qu'ils ne révèlent leur sentiment sur ce point. ZUSAMMENFASSUNG Eltern, die den ersten Fieberkrampf ihres Kindes erleben, denken meistens, daβ es sterben wird 50 Eltern von 36 wegen ihres ersten Fieberkrampfes im Krankenhaus nacheinander aufgenommenen Kindern wurden kurz nach dem Vorfall interviewed. Sehr wenige Eltern erwähnten von sich aus, daß sie geglaubt haben, ihr Kind wiirde sterben, wenn sie aber speziell danach gefragt würden, sagte die Mehrheit der Eltern, sie haben gedacht, ihr Kind wiirde sterben oder sei nahe daran zu sterben. Diese allgemeine Furcht sollte man im Auge behalten, wenn man mit Eltern uber Fieberkrampfe spricht, da sie die Information dariiber eher fur sich behalten als sie offen auszusprechen. RESUMEN Generalmente los padres piensan que su hijo se estd muriendo al verlo con una primera convulsidn febril Cincuenta padres de 36 niños consecutivos ingresados en el hospital à causa de padecer una primera convulsión febril fueron entrevistados poco después del acontecimiento. Muy pocos padres dijeron voluntariamente que habian pensado que su hijo se estaba muriendo, pero cuando fueron preguntados especificamente, la mayoria dijeron que habian pensado que el nifio se estaba muriendo o à punto de morir. Este temor común debe debe ser recordado cuando se discute las convulsiones febriles con los padres, los cuales tienen mas tendencia à ocultarlo que ha ofrecer información voluntariamente acerca del hecho.

PURPOSE: Early detection of diabetic eye disease by dilated eye exam can limit potential vision loss from diabetic retinopathy. The purpose of this study was to examine what variables contribute to diabetes patients not receiving annual dilated eye examinations. METHODS: This study used national 2009 Behavioral Risk Factor Surveillance System survey data. Variables used in the analysis included sociodemographics, insurance status, mentally unhealthy days, receipt of annual dilated eye exams, insulin dependence, a history of diabetes education classes, timely annual diabetic foot exams, and history of cardiovascular disease. Survey proportions were calculated, and survey logistic regression was performed with the consideration of survey strata and weight to correct for biases. RESULTS: The likelihood of receiving annual dilated eye exams was correlated with eight statistically significant variables. These variables included age category, income level, education level, health insurance status, mentally unhealthy days within the past month, insulin dependence, a history of diabetic education classes, and timeliness of annual diabetic foot examinations. CONCLUSIONS: This study provides a snapshot of variables that may have a bearing on diabetes patients seeking annual dilated retinal examinations. Eight variables were statistically significant in affecting the timeliness of diabetic eye examinations. Thus, resolutions for these factors could be implemented for future improvement of comprehensive health care provided to those with diabetes.

OBJECTIVE: Mandatory active surveillance culturing of all patients admitted to Veterans Affairs (VA) hospitals carries substantial economic costs. Clinical prediction rules have been used elsewhere to identify patients at high risk of colonization with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant enterococci (VRE). We aimed to derive and evaluate the clinical efficacy of prediction rules for MRSA and VRE colonization in a VA hospital. Design and setting. Prospective cohort of adult inpatients admitted to the medical and surgical wards of a 119-bed tertiary care VA hospital. METHODS: Within 48 hours after admission, patients gave consent, completed a 44-item risk factor questionnaire, and provided nasal culture samples for MRSA testing. A subset provided perirectal culture samples for VRE testing. RESULTS: Of 598 patients enrolled from August 30, 2007, through October 30, 2009, 585 provided nares samples and 239 provided perirectal samples. The prevalence of MRSA was 10.4% (61 of 585) (15.0% in patients with and 5.6% in patients without electronic medical record (EMR)-documented antibiotic use during the past year; P < .01). The prevalence of VRE was 6.3% (15 of 239) (11.3% in patients with and 0.9% in patients without EMR-documented antibiotic use; P < .01). The use of EMR-documented antibiotic use during the past year as the predictive rule for screening identified 242.8 (84%) of 290.6 subsequent days of exposure to MRSA and 60.0 (98%) of 61.0 subsequent days of exposure to VRE, respectively. EMR documentation of antibiotic use during the past year identified 301 (51%) of 585 patients as high-risk patients for whom additional testing with active surveillance culturing would be appropriate. CONCLUSIONS: EMR documentation of antibiotic use during the year prior to admission identifies most MRSA and nearly all VRE transmission risk with surveillance culture sampling of only 51% of patients. This approach has substantial cost savings compared with the practice of universal active surveillance.

INTRODUCTION: There are very few symptom validity indices directly examining overreported posttraumatic stress disorder (PTSD) symptomatology, and, until recently, there were no symptom validity indices embedded within the PTSD Checklist for the DSM-5 (PCL-5), which is one of the most commonly used PTSD measures. Given this, the current study sought to develop and cross-validate symptom validity indices for the PCL-5. METHOD: = 210). Patients were determined to be valid or invalid responders based on Personality Asessment Inventory symptom validity indices. Three PCL-5 symptom validity indices were then examined: the PCL-5 Symptom Severity scale (PSS), the PCL-5 Extreme Symptom scale (PES), and the PCL-5 Rare Items scale (PRI). RESULTS: Area under the curve statistics ranged from .78 to .85. The PSS and PES both met classification accuracy statistic goals, with the PES achieving the highest sensitivity rate (.39) when maintaining specificity at .90 or above across all criterion groups. When an ad hoc analysis was performed, which included only patients with exceptionally strong evidence of invalidity, sensitivity rates increased to .60 for the PES while maintaining specificity at .90. CONCLUSIONS: These findings provide preliminary support for new PTSD symptom validity indices embedded within one of the most frequently used PTSD measures.

OBJECTIVE: The present study sought to identify changes in neuropsychological validity assessment beliefs and practices relative to surveys of North American neuropsychologists conducted in 2015 and 2016, obtain a more nuanced understanding of such beliefs and practices, and examine salient validity assessment topics not addressed by previous surveys. METHODS: Adult focused neuropsychologists (n = 445) and neuropsychological validity assessment experts (n = 16) were surveyed regarding their perceptions and practices related to the following topics: (i) importance of validity testing; (ii) multiple performance validity test (PVT) administration and interpretation; (iii) suspected causes of invalidity; (iv) reporting on malingering; (v) assessment of examinees of diverse language, culture, and nation of origin; (vi) terminology; and (vii) most frequently utilized validity measures. RESULTS: There was general agreement, if not consensus, across multiple survey topics. The vast majority of neuropsychologists and experts view validity testing as mandatory in clinical and forensic evaluations, administer multiple PVTs regardless of setting, believe validity assessment to be important in the evaluation of all individuals including older adults and culturally diverse individuals, and view evaluations with few to no validity tests interspersed throughout the evaluation as being of lesser quality. Divergent opinions were also seen among respondents and between neuropsychologists and experts on some topics, including likely causes of invalidity and assessment and formal communication of malingering. CONCLUSIONS: Current results highlight the necessity of formal validity assessment within both clinical and forensic neuropsychological evaluations, and findings document current trends and reported practices within the field.

Cataract surgery is the most common procedure performed on Medicare recipients. Many of these patients have been on anticoagulation therapy (ACT) regimens, but no consistent standard currently governs the use or cessation of ACT prior to surgery. This study evaluated the safety of continuing ACT in cataract surgery patients (of ASA III physical status) at seven centers. There was a 53% incidence of previous ACT among the 1,842 individuals sampled. During 2,241 procedures, only two patients (one on ACT) experienced abnormal surgical bleeding, noted as hyphemas. Seventeen (0.9%), nine on ACT and eight not on it, had some type of bleeding related to regional anesthesia; of these, nine had bruising and eight had subconjunctival hemorrhage. No major complications were noted in the ACT group during surgery, or at visits 1 day and 1 week postoperatively.

The Veterans Health Administration (VHA) has provided important contributions to our understanding of multiple sclerosis (MS); however, the characteristics of the modern VHA MS population have not been adequately characterized. Our objectives were to compare and contrast characteristics of the VHA MS population with other contemporary MS cohorts. A cross-sectional, mail-based survey of a stratified, random sample of 3,905 VHA users with MS was conducted. Detailed demographic and clinical data were collected as well as patient-reported outcomes assessing disability and quality of life. A total of 1,379 Veterans were enrolled into the MS Surveillance Registry (MSSR). Respondents did not differ from nonrespondents with regard to demographics or region. When compared to several other contemporary MS cohorts, some demographic differences were noted; however, the age of MS onset and diagnosis, subtype distribution, and most prevalent symptoms were very similar across MS cohorts. The MSSR appears to be representative of the general MS population. Combining the extensive VHA health services encounter data with the MSSR provides a rich and unique cohort for study.

The United States healthcare spending was about $7,681 per resident and accounted for 16.2% of the nation's GDP in 2008 and rose to compromise about 18% of the nation's GDP by 2010. As healthcare sector continues to grow so will its consumption of nonrenewable resources such as energy. Most of the attention in documenting and reducing energy consumption in healthcare has focused on the healthcare facility heating, cooling, ventilation and lighting systems. In this paper we take a different approach in order to gain a more detailed understanding of energy consumption leading to environmental impact information of healthcare services. This paper reports on the preliminary analysis of the energy consumed for Computed Tomography (CT) diagnostic service delivered. It is a part of a larger body of work to catalogue environmental impact information for a number of healthcare services and to relate those data to medical outcomes.

This is the first published article to develop a symptom validity index for the BAI. To minimize false positive errors, a BAI total score of ≥ 36 is recommended.

The goal of this column is to provide historical context on tardive dyskinesia (TD) to help the reader understand how the concept was studied and evolved over time. Psychiatrists today should understand this history and consider it in combination with more recent data on the neurobiology of TD, including data from animal studies. This combination of classic data with modern science can help readers develop a more complete understanding and lead to a more judicious use of the term TD, after consideration of all of the alternative causes of abnormal movements, including spontaneous dyskinesia (SD). We advocate that clinicians use the term SD when in doubt about the cause of a movement disorder in a given patient, as TD is never distinguishable from SD in a given patient but is instead an issue of a statistical odds ratio.

PURPOSE: To validate basic competency in arthroscopic knot tying using a unique simulator device to compare the level of training needed for learning and tying the arthroscopic knot by evaluating the tensile properties of the arthroscopic knots. METHODS: Three groups of surgeons of various experience levels (postgraduate year [PGY] 1, PGY 3, and experienced surgeons) tied 2 different arthroscopic knots (Tennessee Slider, considered easier, and Weston, considered more difficult) over a 10-week period. Each group went through 3 separate stages of knot tying: stage 1, tying 8 knots without cannula or knot pusher; stage 2, tying 12 knots with knot pusher; and stage 3, tying 20 knots with knot pusher through a cannula that simulates knot tying during surgery. A single load-to-failure test was performed and ultimate clinical failure loads were recorded. Time needed to tie each knot was also recorded. RESULTS: At stages 1 and 2, the PGY 1 group had a significantly weak knot tensile strength (Tennessee Slider stage 1: 60 v 129 N, P = .001; Tennessee Slider stage 2: 69 v 132 N, P = .0029; Weston stage 1: 73 v 184 N, P = .0000; Weston stage 2: 125 v 173 N, P = .0045) and were slower (Weston: 56 v 30 seconds, P = .0010) than the experienced surgeon group for both knots. At stage 3, only the initial 2 weeks of Tennessee Slider showed a significant difference between groups 1 and 3 (week 6: 87 v 118 N, P = .0492; week 7: 89 v 126, P = .01485). Even though the Tennessee Slider knot is one of the easier arthroscopic knots to learn to tie, the results showed a slow trend of improvement in this knot-tying skill for group 1 after each stage. CONCLUSIONS: The data validated an important learning effect in all trainees in arthroscopic knot tying over a 10-week period and showed that inexperienced trainees will be able to improve their knot-tying skill with training in 3 stages with a simulator environment. CLINICAL RELEVANCE: The findings of this study indicated the importance of hands-on experience in performing arthroscopic knot tying, as determined by both knot performance and ultimate suture loop strength. In addition, each orthopaedic resident learned and developed his or her arthroscopic knot-tying skills and provided a foundation for his or her future practice in orthopaedic medicine.

This study supports the use of all three proposed BDI-II embedded symptom validity indices.

This series of columns has 3 main goals: (1) to explain class warnings as used by the United States Food and Drug Administration, (2) to increase awareness of movement disorders that may occur in patients treated with antipsychotic medications, and (3) to understand why clinicians should refrain from immediately assuming a diagnosis of tardive dyskinesia/dystonia (TD) in patients who develop abnormal movements during treatment with antipsychotics. The first column in the series presented a patient who developed abnormal movements while being treated with aripiprazole as an augmentation strategy for major depressive disorder (MDD) and reviewed data concerning the historical background, incidence, prevalence, and risk factors for tardive and spontaneous dyskinesias, the clinical presentations of which closely resemble each other. The second column in the series reviewed the unique mechanism of action of aripiprazole and preclinical studies and an early-phase human translational study that suggest a low, if not absent, risk of TD with aripiprazole. This column reviews clinical trial data to assess whether those data support the conclusion that aripiprazole has a low to absent risk of causing TD when used as an augmentation strategy to treat MDD. To date, no randomized, placebo-controlled trials have established a definitive link between exposure to aripiprazole and TD in patients with MDD. One long-term, open-label, safety trial examined aripiprazole as an augmentation strategy in individuals with MDD and found a rare occurrence (4/987, 0.4%, the confidence interval of which overlaps with zero) of an adverse event termed TD. In all 4 cases, the observed movements resolved within weeks of aripiprazole discontinuation, suggesting that they were either amenable to treatment or represented an acute syndrome rather than TD. No cases of TD were reported in the registration trials for the MDD indication for aripiprazole. These data were presented in a pooled analysis of three, 14-week studies involving 1088 subjects, 409 of whom were elderly like the 76-year-old individual presented in the case in the first column of this series. Finally, 3 short-term studies evaluated the use of aripiprazole in patients with psychosis associated with Alzheimer disease, a population who would be considered a relatively higher risk group for developing TD when exposed to antipsychotics and that also closely matches the patient in the case presented at the beginning of this series in terms of age. No incidence of TD was reported in this sample and mean scores on the Abnormal Involuntary Movement Scale decreased in individuals exposed to aripiprazole compared with those on placebo. On the basis of results of this review and data from registration trials of aripiprazole for all indications, the potential (or raw) incidence of what was termed TD occurred at rates ranging from 0.004 (4/987) based on long-term safety data from the program investigating aripiprazole augmentation treatment in MDD, to 0.0016 (19/11,897) based on the total safety database from aripiprazole registration trials for all indications, to 0 in trials in elderly individuals with Alzheimer disease. The confidence intervals for all of these potential incidence rates overlap with zero. The next column in this 5-part series reviews 37 case reports that reported TD in association with aripiprazole treatment and 27 case reports that suggested an improvement in preexisting TD with aripiprazole treatment. The fifth and final column in this series will discuss the types of prohibitively expensive and logistically difficult studies that would be needed to determine whether a definitive causal relationship between aripiprazole and TD exists.

Arthroscopic knot tying requires practice and attention to detail, especially tying the 3 reversing half-hitches on alternating posts (RHAPs) in a knot. Mistakes can occur that result in an unintentional tension (>10 N) applied to the wrapping suture limb, and by placing tension in the wrong limb, the previously "flipped" half-hitch is converted from a series of RHAPs into a series of identical half-hitches on the same post, thereby producing insecure knots or suture loops. This was hypothesized to be a source of knot failure by knot slippage. This error can be avoided by using a technique we describe as "reverse flipping," which purposely "flips" the half-hitch down at the main knot while tying the 3 RHAPs in a knot, and then the half-hitch is retightened using either a past-pointing or over-pointing technique. This way the surgeon can be absolutely sure that the half-hitch is tightened in the direction that it was intended to be placed, and can also prevent the unintentional tension applied to the wrapping suture limb that causes the half-hitch to "flip." However, caution should be used when tensioning the half-hitches; overtensioning (>40 N) during past-pointing or over-pointing could also potentially "flip" the previous half-hitch that has already been tightened and cause potential knot failure.

BACKGROUND: Generalized anxiety disorder (GAD) and major depressive disorder (MDD) are prevalent in patients with asthma. These disorders may increase asthma severity and decrease asthma control. No studies have evaluated the impact of achieving antidepressant target dose optimization compared with not achieving antidepressant target doses on asthma control in uninsured and underinsured patients. OBJECTIVE: To evaluate the impact of achieving antidepressant target dose optimization in uninsured and underinsured adult asthma patients with GAD and/or MDD on the risk of severe asthma exacerbations and number of asthma-related outcomes. METHODS: We conducted a retrospective cohort study of uninsured and underinsured adult asthma patients with GAD and/or MDD who have been initiated on a single antidepressant and maintained on a stable dose for 8 weeks (index date). Eligible patients were followed for 12-24 months after the index date and separated into those who achieved a target dose (target group) and those who did not (control group). Poisson regression was used to compare the risk of severe exacerbations, and analysis of covariance was used to compare the number of severe exacerbations and other asthma-related outcomes between the target and control groups during the 1- and 2-year post-index periods. RESULTS: A total of 61 patients (24 in the target group and 37 in the control group) met inclusion criteria. The target group had a reduced risk of severe asthma exacerbations compared with the control group during the 1-year post-index (adjusted risk reduction [RR] 0.46, 95% confidence interval [CI] 0.26-0.82) and 2-year post-index (adjusted RR 0.5, 95% CI 0.3-0.82) periods. The target group also experienced a lower number of severe asthma exacerbations and other asthma-related outcomes during the 1- and 2-year post-index periods compared with the control group after adjusting for confounders. CONCLUSIONS: Among uninsured and underinsured asthma patients with GAD and/or MDD who were initiated on a single antidepressant, those who were titrated to achieve target doses had a reduced risk of severe asthma exacerbations and a lower number of asthma-related outcomes than those who were not optimized to achieve target doses.

Coordinating and integrating mental health topics into emergency preparedness planning is a critical step for ensuring effective response to the psychological issues connected with trauma. In order to remedy the current lack of integration, potential response providers must receive effective mental health preparedness training. The current study provided mental health preparedness training to public health and allied health professionals in Kansas and assessed the impact of the training on perceived mental health preparedness knowledge. Participants included 157 potential first and secondary responders from public health and allied fields who attended one of 10 training presentations on mental health emergency preparedness. Pre- and post-presentation, participants responded to six Likert-scale questions about their perceived knowledge of topics and level of mental health preparedness. Questions addressed common psychological responses to disaster or terrorist events, stress reactions of specific populations, psychological resiliency, mental health preparedness integration, and level of agency preparedness. Post-training, participants reported statistically significant (p<0.001) increases in perceived level of knowledge on all topics. Participants were also significantly more likely (p<0.001) to report that their agency could respond to the mental health issues related to a disaster or emergency. The current study provides data about gaps in practitioner knowledge regarding mental health preparedness in Kansas. While the self-report nature of responses is a limitation, these findings serve as the first step toward producing and implementing effective mental health preparedness information and training on a wide scale.

INTRODUCTION: This study cross-validates and expands upon previous research by examining the optimal number of PVT failures necessary to determine invalid performance when 10 PVTs are administered during a neuropsychological evaluation. Additionally, the study assessed the degree of skewness of individual PVTs and PVT intercorrelations for the overall sample and by validity group. METHOD: = 58; base rate of 20% performance invalidity) performance based on four independent criterion PVTs. Failure rates of 10 additional PVTs were then compared, and sensitivity and specificity were calculated at different thresholds (e.g. ≥1, ≥2, ≥3, ≥4 PVT failures) to determine the optimal threshold for detecting invalid performance while maintaining ≥ 90% specificity. RESULTS: Findings indicate that failing ≥ 2 PVTs yielded 86% sensitivity/76% specificity, failing ≥ 3 PVTs yielded 69% sensitivity/92% specificity, failing ≥ 4 PVTs yielded 57% sensitivity/96% specificity, failing ≥ 5 PVTs yielded 29% sensitivity/99% specificity, and failing ≥ 6 PVTs yielded 22% sensitivity/100% specificity. PVT intercorrelations were generally small for the overall sample and by validity group. As expected, data were more highly skewed for patients with valid performance. CONCLUSIONS: Findings were consistent with previous research and demonstrate that the three-failure threshold optimally detects invalid performance when 10 PVTs are administered. These findings inform the use of multiple PVTs in clinical settings and aid in the interpretation of PVT results.

INTRODUCTION: Three symptom validity indices have recently been developed for the PTSD Checklist for DSM-5 (PCL-5). To date, these validity indices have been examined in North American research and clinical samples, generally with promising results. The current study aimed to cross-validate the symptom validity indices in a cross-cultural forensic sample. METHOD: = 79) were Balkan (Macedonian, Kosovar, and Serbian) contractors previously employed at United States military bases in Afghanistan and Iraq. Examinees claimed posttraumatic stress disorder (PTSD) secondary to alleged adverse experiences, and they were pursuing Federal Workers' Compensation claims for PTSD under the auspices of the Defense Base Act. In this study, validity status was determined via outcome on the Inventory of Problems-29. RESULTS: There were no significant differences between most demographic and background variables when groups were divided by validity status. Conversely, scores on all validity tests were significantly different between the group of examinees who were likely credibly presenting and the group that was likely noncredibly responding; medium to large effect sizes were observed. Area under the curve statistics ranged from .73 to .77. Sensitivity rates ranged from .33 to .47 when specificity was held at .90 or higher. CONCLUSIONS: The findings converge well with prior research results, extending the use of PCL-5 symptom validity indices to a cross-cultural forensic sample.

This series of columns has 3 main goals: (1) to explain class warnings as used by the United States Food and Drug Administration, (2) to increase awareness of movement disorders that may occur in patients treated with antipsychotic medications, and (3) to understand why clinicians should refrain from immediately assuming a diagnosis of tardive dyskinesia/dystonia (TD) in patients treated with antipsychotics. The first column in this series began with the case of a 76-year-old man with major depressive disorder who developed orofacial dyskinesias while being treated with aripiprazole as an antidepressant augmentation strategy. It was alleged that a higher than intended dose of aripiprazole (ie, 20 mg/d for 2 wk followed by 10 mg/d for 4 wk instead of the intended dose of 2 mg/d) was the cause of the dyskinetic movements in this man, and the authors were asked to review the case and give their opinion. The principal basis for this theory of causation was the class warning about TD in the package insert for aripiprazole. The rationale for concluding aripiprazole caused TD in the 76-year-old man led to this series of columns about aripiprazole, its potential--if any--to cause TD, and the presence of a class warning about TD in its package insert. The central point is to illustrate why class warnings exist and their implications for practice. The first column in this series focused on the historical background, incidence, prevalence, risk factors, and clinical presentations of tardive and spontaneous dyskinesias and concluded with a discussion of diagnostic considerations explaining why clinicians should avoid making a diagnosis of TD until a thorough differential diagnosis has been considered. This second column in the series reviews the pharmacology of aripiprazole and the preclinical and phase I translational human studies that suggest aripiprazole should have a low to nonexistent risk of causing TD compared with other antipsychotics. The third column in the series will review the systematic clinical trial data and "real-world" data on TD and the use of aripiprazole as adjunctive treatment with antidepressants for major depressive disorder to see whether these data support the conclusion of a low to nonexistent relationship between aripiprazole treatment and the development of TD. The fourth and final column in the series will consider the type of study that would need to be performed to avoid a specific class warning, focusing on the TD class warning as an example and discussing why such studies are rarely done.