Showing papers in "Journal of Psychiatric Practice in 2003"

What do consumers say they want and need during a psychiatric emergency

Abstract: Behavioral emergencies are a common and serious problem for consumers, their families and communities, and the healthcare providers on whom they rely for help. In recent years, serious concerns about the management of behavioral and psychiatric emergencies-in particular, the misapplication and overuse of physical and chemical restraints and seclusion-have become a focus of attention for mental health professionals and policy makers as well as for the lay public, the media, and patient advocacy organizations. Policy leaders and clinicians are searching for ways to balance the rights of consumers with considerations of safety and good care in an area in which it is difficult to conduct research. A survey of mental health professionals who are experts on the treatment of psychiatric and behavioral emergencies identified consumer input and collaboration between patient and clinician whenever possible as being extremely important in achieving the best short-term and particularly the best long-term outcomes for patients. The survey of consumer perspectives described in this article was undertaken in response to the need to better understand consumer experiences and preferences. The authors describe four emergency services forums conducted in 2002, which involved a total of 59 consumers. Each forum involved a written consumer survey as well as a workshop to develop and prioritize recommendations for improving psychiatric emergency care. The authors present the results of the consumer survey and summarize the top recommendations from the workshops. In both the survey and the workshops, the consumers repeatedly stressed the importance of having staff treat them with respect, talk to them, listen to them, and involve them in treatment decisions. There were a number of important areas of agreement between the recommendations of the consumer panel and those of the experts in emergency psychiatry surveyed for the Expert Consensus Guidelines on the Treatment of Behavioral Emergencies. These include the desirability of verbal interventions, the use of a collaborative approach, and the use of oral medications guided by the individual consumer's problems, medication experiences, and preferences. The majority of the consumer panel reported adverse experiences with general hospital emergency rooms and, in fact, called for the development of specialized psychiatric emergency services such as those recommended in the Expert Consensus Guidelines. One-fifth of the consumer panel attributed their emergency contact to lack of access to more routine mental health care. The consumers clearly do not reject medications categorically. Almost half indicated that they wanted medications and a similar number indicated benefit from medications, although many complained of forced administration and unwanted side effects. The consumer panel preferred benzodiazepines and ranked haloperidol as a least preferred option. Among their key recommendations for improving psychiatric emergency care, the consumer panel stressed the development of alternatives to traditional emergency room services, the increased use of advance directives, more comfortable physical environments for waiting and treatment, increased use of peer support services, improved training of emergency staff to foster a more humanistic and person-centered approach, increased collaboration between practitioners and patients, and improved discharge planning and post-discharge follow-up. The implications of these findings for improving psychiatric emergency care are considered.

Elements of successful restraint and seclusion reduction programs and their application in a large, urban, state psychiatric hospital

Abstract: In recent years, there has been a strong desire on the part of inpatient psychiatric programs to reduce the use of seclusion and mechanical restraint. There is a consensus among those who have published descriptions of successfully implemented restraint and seclusion reduction programs that the essential elements of such programs are high level administrative endorsement, participation by recipients of mental health services, culture change, training, data analysis, and individualized treatment. This article describes these elements and their application in a successful restraint reduction program at Creedmoor Psychiatric Center, a large, urban, state-operated psychiatric hospital that reduced its combined restraint and seclusion rate by 67% over a period of 2 years.

Impact of trauma on children.

Abstract: Millions of children are affected by physical and sexual abuse, natural and technological disasters, transportation accidents, invasive medical procedures, exposure to community violence, violence in the home, assault, and terrorism. Unfortunately, the emotional impact of exposure to trauma on children is often unappreciated and therefore untreated, and yet the impact of exposures to disaster and violence is profound and long-lasting. This article first briefly discusses the epidemiology of trauma in children, and then reviews the psychiatric and neurodevelopmental impact of trauma on children as well as the effects of trauma on children's emotional development. Trauma in children can lead to the development of posttraumatic stress disorder as well as to a variety of other psychiatric disorders, including depression, generalized anxiety disorder, panic attacks, borderline personality disorder, and substance abuse in adult survivors of trauma. Research has found that early exposure to stress and trauma causes physical effects on neurodevelopment which may lead to changes in the individual's long-term response to stress and vulnerability to psychiatric disorders. Exposure to trauma also affects children's ability to regulate, identify, and express emotions, and may have a negative effect on the individual's core identity and ability to relate to others. The authors also discuss what has been learned, based on recent experiences such as the World Trade Center catastrophe, about the role of television viewing in increasing the effects of traumatic events. The last section of the article provides guidance concerning the identification and clinical treatment of children and adolescents who are having emotional problems as a result of exposure to trauma.

Hyperprolactinemia and schizophrenia: mechanisms and clinical aspects.

Abstract: The association between elevated prolactin levels and conventional antipsychotics is well-established. The novel antipsychotic, risperidone, has also been shown to elevate prolactin levels. Patients undergoing treatment with these medications are at high risk for developing hyperprolactinemia, which is associated with decreased bone mineral density, osteoporosis, menstrual disruptions and infertility, galactorrhea, breast cancer, cardiovascular disorders, and sexual impairment. Patients treated with conventional antipsychotics and risperidone should be routinely screened for hyperprolactinemia, and monitored for known sequelae. Optimally, patients with hyperprolactinemia secondary to antipsychotic drug treatment should be switched to a prolactin-sparing antipsychotic. This review will briefly highlight the regulation and function of prolactin secretion, discuss clinical effects of antipsychotic-induced hyperprolactinemia, and suggest a course of treatment.

Psychiatric disorders in individuals with pervasive developmental disorder.

Abstract: Pervasive developmental disorders (PDD) refer to the group of heterogeneous conditions that make up a continuum or spectrum of autistic disorders and share a core triad of impairments consisting of qualitative disturbances in social interaction and verbal and nonverbal communication and imagination. It has long been believed that the prevalence of autism was 2-4 per 10,000 children. However, studies using broader definitions of autistic disorder have suggested that the prevalence of autism spectrum disorder may be as high as 90 per 10,000 and that a greater proportion of individuals with PDD have intellectual levels above 70. Clinicians and researchers have commented on the apparent increase in prevalence of the disorder and have offered a number of explanations, including better recognition and diagnosis of the autism spectrum of disorders and a real increase in the disturbance. It is being increasingly recognized that individuals with PDD are at risk for a wide array of psychiatric disturbances, including affective disorder, anxiety disorders, schizophrenia-like psychosis, aggression, antisocial behavior, and Tourette's disorder (TD). Evidence indicates that PDD is significantly related to the comorbid psychiatric disorders and TD. Because PDD is not rare, individuals with autism spectrum disorder may represent significant subgroups of severely emotionally disturbed patients referred for psychiatric treatment. Because of lack of awareness that the clinical manifestations of PDD are heterogeneous and often mild and that comorbid psychiatric disturbances may obscure the symptoms of the developmental disorder, the diagnosis of PDD may be missed. Implications for practicing clinicians are discussed.

The cholinesterase inhibitors.

Abstract: Dementia is a serious and growing problem that presents enormous burdens to patients, their families, and national healthcare systems throughout the world. In the United States, there are currently two classes of psychopharmacologic agents approved for the treatment of Alzheimer’s disease: the cholinesterase inhibitors, which are approved for use in patients with mild to moderate disease, and memantine, an N-methyl-D-aspartate (NMDA) receptor antagonist, which is approved for treatment of moderate to severe illness. Three cholinesterase inhibitors are in general clinical use, each of which has a distinct pharmacokinetic, pharmacodynamic, and side-effect profile. In addition, there is growing research and clinical evidence of the effectiveness of the cholinesterase inhibitors in patients who are in the more advanced stages of Alzheimer’s dementia as well as in patients with other forms of dementia.

Treatment of behavioral emergencies: a summary of the expert consensus guidelines

Abstract: Objectives.Behavioral emergencies are a common and serious problem for consumers, their communities, and the healthcare settings on which they rely, but there is little research to guide provider responses to this challenge. Key constructs such as agitation have not been adequately operationalized s

Comprehensive review of hepatitis C for psychiatrists: Risks, screening, diagnosis, treatment, and interferon-based therapy complications

Abstract: Hepatitis C is an RNA virus responsible for chronic infection in at least 4 million Americans. Patients are often unaware that they have contracted the virus until the appearance of long-term consequences of the infection, primarily cirrhosis and hepatocellular carcinoma. Many patients with hepatitis C have comorbid psychiatric and/or substance abuse disorders. Treatments for hepatitis C infection are based on interferon-alfa therapy and have shown increasing effectiveness in recent years; however, interferon-alfa therapy also poses significant risks for physical and neuropsychiatric side effects. Since psychiatrists often serve as primary caregivers for patients who are at higher risk for hepatitis C infection, knowledge about the diagnosis, prognosis, and treatment of this disease is needed. In the first half of this article, the authors review the epidemiology, transmission, pathophysiology and disease course of hepatitis C, as well as the neuropsychiatric complications of hepatitis C infection. They also discuss the incidence of comorbid psychiatric disorders in patients with hepatitis C infection and consider the impact of the infection on patients' quality of life. The authors then provide an overview of the clinical management of HCV infection, including screening procedures, decision-making about treatment, available treatments (interferon-alfa, pegylated interferon-alpha, combination therapy with interferon and ribavirin) and their side effects and potential drug-drug interactions, and prediction of treatment response. The authors then discuss management of the neuropsychiatric complications of treatment with interferon-alpha and ribavirin, including depression, mania and psychosis, and cognitive and neurological complications. The final section of the article focuses on special issues related to the treatment of hepatitis C infection in patients with substance abuse or dependence and/or other comorbid psychiatric illness.

Reproducibility of the in vivo effect of the selective serotonin reuptake inhibitors on the in vivo function of cytochrome P450 2D6: an update (part II).

Abstract: There is a reciprocal relationship between all three variables in Equation 1. This fact is particularly obvious with the first two variables: Drug concentration determines which of the drug’s potential sites of action will be engaged and to what degree. Conversely, the affinity of the drug for a site of action determines the concentration of the drug that must be achieved to affect that site of action to a physiologically relevant degree. The third variable in Equation 1 refers to the biological differences among patients that can shift their position on the usual dose-response curve, thus making them more or less responsive to the drug (i.e., “sensitive” or “resistant”).1 Such differences may be mediated through site(s) of action and/or through the mechanisms of pharmacokinetics. As illustrated in Equation 1, biological differences among patients may be genetically determined (i.e., mutations in the gene[s] coding for the site[s] of action or the gene[s] coding for the mechanisms mediating the absorption, distribution, metabolism or elimination characteristics of the drug). They may also be due to disease-related changes in either the site of action or the pharmacokinetics of the drug. An example of a diseaserelated change in site of action is the loss of dopamine neurons in the brains of patients with Parkinson’s disease, which makes these patients more sensitive to the extrapyramidal side effects of dopamine antagonists (e.g., haloperidol). An example of a disease-related change that affects the pharmacokinetics of a drug is the slowing of drug clearance caused by a reduction in left ventricular stroke volume, which in turn leads to a reduction in hepatic and renal blood flow and hence drug clearance. There are also age-related changes in physiology that can affect these variables. Finally, there are internal environmental changes that result from the ingestion of substances, which, by virtue of their presence in the body, can alter the response to another drug. These substances may be dietary (e.g., grapefruit juice), herbs (e.g., St. John’s Wort), or drugs (e.g., antidepressants). A considerable amount of research effort has focused on the fact that some antidepressants under usual dosing conditions are capable of inhibiting one or more human drug metabolizing enzymes and can thus cause substantial elevations in the blood levels of specific coprescribed drugs. That work initially caused some confusion and controversy concerning the reproducibility of these effects and their clinical implications.2 This column will provide an update concerning the effects of the selective serotonin reuptake inhibitors (SSRIs) on one specific human drug metabolizing enzyme, cytochrome P450 (CYP) 2D6. For a more detailed discussion of these issues and those reviewed in the sections that follow, readers are referred to two publications by the author3, 4 and the chapter on antidepressants by Shad and Preskorn in Metabolic Drug Interactions.5

Neuroimaging studies of violence and antisocial behavior.

Abstract: The neurobiological basis of violence and antisocial behavior is poorly understood. Lesion studies have implicated the frontal and temporal lobes in such phenomena. Recent neuroimaging studies have provided more detailed information on the neurobiological correlates of violence and antisocial behavior. Moreover, the results of such imaging studies extend findings from prior lesion studies. These results suggest that violent and antisocial behavior is associated with disruptions in frontotemporal neural systems. This article reviews the neuroimaging literature on violence and antisocial behavior and discusses the strengths and weaknesses of the different methods that have been used in such studies. The author reviews findings from cerebral psychophysiology studies (electroencephalographic studies and evoked potentials), as well as from studies using positron emission tomography (PET), single photon emission computed tomography (SPECT), and magnetic resonance imaging (MRI). The article concludes with a discussion of useful directions for future research. It is clear that the use of neuroimaging methods in combination offers the greatest promise for progress in the understanding of the neural basis of violence and antisocial behavior.

The controversy over "chemical restraint" in acute care psychiatry.

Abstract: In many healthcare settings, medications are considered a less invasive alternative to the use of physical restraint for agitated patients experiencing a behavioral crisis, a practice that is often referred to as "chemical restraint." However, recent federal regulations appear to equate chemical and physical restraint and to characterize both as extraordinary practices that should not be undertaken lightly. Although many clinicians consider the term "chemical restraint" pejorative, since it does not reflect the possibility that forced medication may be clinically necessary and have a beneficial effect, the term is embedded in recent regulatory language. The author first reviews the controversy over the concept of chemical restraint as it has developed in the mental health literature and regulatory policy. As yet there is no consensus among clinicians or policy makers whether such use of medications is a form of coercion or a form of patient-focused intensive care. The author then discusses precipitants of emergency care and clinical factors and situations that may lead to the use of medications in a way that might be considered chemical restraint. Such factors include clinical and demographic characteristics of patients, institutional characteristics, and staff perception and attitudes. In the final section of the article, the author reviews the recommendations concerning the emergency use of medications given in the Expert Consensus Guidelines on the Treatment of Behavioral Emergencies and discusses treatment developments that have occurred since the time of the survey on which those guidelines were based.

Psychiatric advance directives.

Abstract: Psychiatric advance directives are gaining attention as the number of consumers seeking metal health services increases. Even though medical advance directives have existed for years, psychiatric advance directives are in their infancy. The goal of these directives is to increase patient autonomy and decrease coercive treatment. Although this concept sounds simple, advance directives have generated heated debates that encompass ethics, law, and medicine. Psychiatric advance directives are also not universally accepted--only 14 states currently recognize such directives. This review article discusses the premise behind psychiatric advance directives and explores possible benefits and obstacles to the use of such directives.

Cardiovascular health and depression.

Abstract: Research has shown that depression increases the likelihood that otherwise healthy people will develop ischemic heart disease (IHD) and worsens the prognosis of patients who already have IHD. Moreover, concerns about safety (e.g., cardiac side effects, drug-drug interactions) have caused physicians to be hesitant about using antidepressant agents in patients with IHD. This article is based on a recent roundtable of experts who met to discuss risk, diagnosis, and treatment options for depression in patients with IHD. This article reviews clinical and epidemiological studies that have described a link between depression and the subsequent development of IHD and have examined the role of depression as a predictor of cardiac events in patients with existing IHD. The article addresses the issue of whether depression can be safely and efficaciously treated both in patients with stable IHD and in those with acute coronary syndromes. The authors discuss safety issues related to the potential for interactions between antidepressants and cardiovascular medications, the use of nonpharmacologic treatment options such as psychosocial interventions, and the effect of antidepressant therapy on quality of life in patients with IHD. The article concludes with practical clinical guidance concerning the management of depression in patients who have recently experienced myocardial infarction.

Classification of neuropsychiatric medications by principal mechanism of action: a meaningful way to anticipate pharmacodynamically mediated drug interactions (part II).

Abstract: This article, the conclusion of a two-part series (see September 2003 for Part I 1), presents a table summarizing the effects of neuropsychiatric medications based on their mechanism(s) of action and by extension their potential to interact pharmacodynamically. This two-part series further develops

The value of therapeutic communities in the treatment of personality disorder: a suitable place for treatment?

Abstract: In the United Kingdom, a government program investigating the links between offending and personality disorder has stimulated renewed interest in the treatment of personality disorders. One psychosocial treatment option for patients with personality disorders is the therapeutic community (TC). In 2000, the authors conducted a small qualitative study with a sample of psychiatrists which suggested that TCs were not well understood and that the status of evidence on efficacy might be partly responsible for low referral numbers. This article reviews the evidence for the efficacy and cost-effectiveness of TCs as a treatment for personality disorders and considers which types of disorders are amenable to TC treatment. We conclude that there is a strong case for more rigorous evaluation and that some of the difficulties anticipated in applying randomized clinical trial (RCT) methodology to the study of TCs could be overcome.

Perception of depot antipsychotics by mental health professionals.

Abstract: Objective: This study examines attitudes of mental health professionals about the use and usefulness of depot antipsychotic medications and determines similarities and differences in attitudes between professional groups. Methods: Mental health professionals working with patients with severe mental illness completed a questionnaire designed to evaluate their opinions concerning rate of depot use, indications for use of depots, problems with use of depots, common side effects of depots, barriers to switching from depot to oral atypical antipsychotics, impact of staffing levels on drug choice, and relative confidence in various antipsychotics for the management of chronic psychosis. Results: Overall, all professional groups perceived depot antipsychotics as a requirement for the treatment of those with serious mental illness who were poorly adherent. However, there were a number of professional differences in responses to certain items in the survey that probably reflected the degree of direct contact with patients. Medical staff were remarkably uniform in their opinions on the use and usefulness of depots. Mental health staff from all the professional groups surveyed considered extrapyramidal side effects (EPS) a major concern, while few rated cognitive side effects, sexual side effects, and weight gain as significant concerns, even though these problems are reported to be a principal concern of patients. Although all professional groups indicated an awareness of the potential toxicity of depot antipsychotics and there was an overall consensus that atypical antipsychotics are likely to be beneficial in chronic psychosis, limitations in resources were seen as a barrier to switching. Conclusions: Attitudes concerning the usefulness and rationale for use of depot antipsychotics differ by medical profession. Nursing and allied health workers are more likely than medical staff to note patient specific variables such as weight gain, injection site reactions, and patient preferences as problems with depots. The results also suggest that, in a community-based psychiatric care system, the use of newer and potentially better agents for the management of psychosis is impaired by resource limitations in service delivery as well as by educational disparities between the professions.

Trauma-related mental health needs and service utilization among female veterans.

Abstract: Women constitute a growing segment of the military veteran population and researchers have begun to examine the extent to which their mental health needs are appropriately addressed within the Veterans Affairs (VA) healthcare system. Existing research documents high rates of both military and non-military trauma among female veterans; however, little has been done to examine the extent to which female veterans exposed to trauma receive treatment for trauma-related problems such as posttraumatic stress disorder (PTSD) and substance abuse within the VA system. This article reviews the literature documenting a high rate of trauma exposure among female veterans and examines evidence that trauma-related mental health problems, such as PTSD and substance-use problems, are under-diagnosed and under-treated among female veterans in VA healthcare settings. The few available studies examining general service utilization among female veterans are also reviewed, and implications for future research and clinical practice in the area of female veterans' trauma-related mental health needs and service use patterns are discussed. In order to provide more accurate assessments of female veterans' trauma-related mental health needs, researchers are encouraged to implement comprehensive trauma assessments as well as clinically valid PTSD and substance abuse diagnostic assessments. Researchers are also encouraged to examine the availability and efficacy of both VA and non-VA mental health services to determine the appropriateness of women's VA service use patterns. Clinicians providing VA mental health services for women are encouraged to include comprehensive, behaviorally-specific trauma interviews and diagnostic evaluations for PTSD and substance-related problems in their standard assessment protocols.

Emerging psychotherapies for eating disorders.

Abstract: Eating disorders are serious illnesses associated with significant medical and psychological sequelae and, in the case of anorexia nervosa, significant mortality. Established psychotherapies such as cognitive-behavioral therapy and interpersonal therapy are effective for many patients with eating disorders. However, these treatments fail to yield full long-term remission in a substantial number of patients. There is a need for novel psychotherapeutic approaches for patients with eating disorders. The authors review three promising new treatment approaches in the field of eating disorders. Motivational enhancement therapy is based on established motivational principles for treating patients with addictive disorders and has been adapted as an early component of treatment for patients with anorexia nervosa and bulimia nervosa. Dialectical behavioral therapy was initially developed for the treatment of borderline personality disorder and has been successfully applied to patients with binge eating. A novel form of family therapy, the Maudsley family treatment for adolescents with anorexia nervosa, has been newly manualized, and studies using this treatment are ongoing. For each treatment, the authors review the theory and techniques of treatment and then go on to review existing data on treatment efficacy.

When do antidepressants worsen the course of bipolar disorder

Abstract: Bipolar disorder may be more prevalent than previously believed. Because a substantial number of patients with bipolar disorder present with an index depressive episode, it is likely that many are misdiagnosed with unipolar major depression. Even if a correct diagnosis is made, depressive symptoms in bipolar disorder are notoriously difficult to treat. Patients are often treated with antidepressants, which, if used improperly, are known to induce mania and provoke rapid cycling. This article explores diagnostic conundrums in bipolar depression and their possible solutions, based on current research evidence. It also elucidates current evidence regarding the risks and benefits associated with antidepressant use and evaluates alternative treatment regimens for the depressed bipolar population, including the use of traditional mood stabilizers such as lithium, novel anticonvulsants such as lamotrigine, and atypical antipsychotics.

The causes of schizophrenia: neurodevelopment and other risk factors.

Abstract: Understanding the etiology of schizophrenia has been a considerable challenge. The neurodevelopmental hypothesis has held sway in recent years, focusing our attention on biological causes acting in early life. Much evidence supports this hypothesis and risk factors operating in early life (e.g., obstetric complications) have been shown to be associated with the later development of schizophrenia. Indicators of abnormal neurodevelopment that characterize individuals vulnerable to later developing schizophrenia have also been identified. For example, as a group, children who will later develop schizophrenia subtly differ from their peers in terms of their motor, cognitive, and social functioning. However, there is much that cannot be explained in purely neurodevelopmental terms. There is growing evidence of associations between the risk of schizophrenia and factors such as drug misuse, ethnicity/migration, life events, and urbanicity. A multifactorial model of causation that encompasses biological, social, and psychological elements is arguably both a better representation of current research findings and a more appropriate model for clinical practice.

Forensic use and abuse of psychological tests: multiscale inventories.

Abstract: 316 July 2003 Properly used, many psychological tests are very useful diagnostic and clinical tools. They often clarify ambiguous information, elicit previously unavailable data, and add objectivity, validity, and reliability to patient interactions and record reviews. Unfortunately, some instruments do not live up to these objectives, especially in forensic cases and/or in the hands of those without specialized psychometric training. This month’s guest columnist, one of America’s most prominent forensic psychologists, discusses a widely used type of test, multiscale inventories, and focuses on three of the most commonly employed measures for impaired populations.

Treatment-refractory mood disorders: a psychodynamic perspective.

Abstract: Treatment-refractory mood disorders pose a significant problem for clinicians. Although biological approaches are usually emphasized in the treatment of patients with these disorders, preliminary findings from an ongoing, naturalistic, longitudinal study of treatment outcome support the notion that a subset of patients with treatment-refractory mood disorders may respond to careful integration of a psychodynamic therapeutic approach into the customary biological approaches. Ten psychodynamic principles that appear to be useful in work with patients with treatment-refractory mood disorders were identified based on a review of the records of 28 patients who were treated using this approach. These principles are presented, discussed, and illustrated by material from a representative case study.

Risk assessment, prediction, and foreseeability.

Abstract: 82 January 2003 Risk assessment is a hot topic in both clinical and forensic psychiatry. It is usually framed in terms of prediction (e.g., predicting suicide, predicting dangerousness, predicting relapse). This month, in spite of nearly axiomatic views that psychiatrists and other clinicians can’t predict dangerousness or suicide, I’ll briefly discuss some ways in which we can assess risk and some common misunderstandings about our “predictions.” No, I’m not going to say we know which patients will meet (or cause) tragedy and when they’ll do it. The subtle wording shift in the preceding paragraph—from “predict” to “assess risk”—is the key. Clinician-readers know that we assess risk in many different situations, from admission evaluations to commitment opinions to decisions about patient passes and discharge. Sometimes, of course, risk assessment is very hard. It is unreasonable to expect a clinician or clinical team to come up with the right answer every time. Sometimes there is no right answer at all. We’ll focus on the idea that risk assessment is logical and can often be done well.

A public health response to a cluster of suicidal behaviors: clinical psychiatry, prevention, and community health.

Abstract: Objective To develop and implement a community public health response to a suicidal behavior cluster, including collection of risk factor data in order to prevent further behaviors. Methods A three-phase response, including school-wide educational debriefings, individual screening for referrals, and on-site crisis management, was implemented. Incidence of suicidal behaviors and their association with hypothesized risk factors were measured. Results Thirty-three percent of students were screened. Depression and poor social functioning were associated with an increased risk of suicidal ideation. Poor social functioning and school adjustment were associated with an increased risk of suicide attempts. Conclusions Development and implementation of a timely public health response, including elucidation of critical risk factors, might prevent further suicidal behaviors.

Optimizing lithium treatment in bipolar disorder: a review of the literature and clinical recommendations.

Abstract: While the past decade has witnessed a major proliferation of putative treatments for bipolar disorder, one medication--lithium--has proven its effectiveness through 50 years of clinical experience and scientific scrutiny. Unfortunately, because the generic compound, lithium, lacks the financial support of its newer, patented comparators, it is often neglected by clinicians who are exposed to continuing medical education (CME) and residency training programs that are heavily weighted towards the newer treatments. This article critically examines the medical literature on lithium's efficacy, anti-suicidal properties, and adverse effects. The authors present research-based recommendations for maximizing lithium's benefits and minimizing adverse effects associated with lithium in patients with bipolar disorder.

Diagnosis and treatment of chronic depression in children and adolescents.

Abstract: Chronic unipolar depression is being increasingly recognized in general psychiatry as a particularly severe form of depressive illness that leads to significant symptomatology, prolonged suffering, and prolonged functional impairment in a variety of domains, including educational/vocational dysfunction as well as interpersonal impairment. Recent research on treatment interventions for adult patients with chronic depressions suggests that standard treatments for depressive illness may need modification to benefit patients with chronic illness. Little attention at this point has been given to the problem of chronic depression in children and adolescents. Many adults with chronic depressive disorders had onset of depression in their childhood or adolescence, making early identification of this form of illness a priority. The authors present a comprehensive review of emerging literature in the assessment, clinical course, and treatment of chronic forms of unipolar depression in youth. They then develop summary recommendations for the assessment and treatment of this type of mood disorder in youth, based on the currently available research and common sense clinical experience.

A paradigm for treatment of inpatient psychiatric disorders: from asylum to intensive care.

Abstract: ObjectiveNo articles, chapters, or texts have been published in the last 5 years that detail a workable model of inpatient psychiatric treatment based on current, drastically changed realities.MethodsWe reviewed controlled studies on inpatient psychiatric care and pooled our clinical experience from

Borderline patients at the border of treatability: at the intersection of borderline, narcissistic, and antisocial personalities.

Abstract: The author discusses the difficulties involved in treating patients with borderline personality disorder and concomitant Cluster B-narcissistic, histrionic, and/or antisocial-personality traits or disorders. He presents eight vignettes of patients with borderline personality disorder combined with various types of Cluster B personality traits or disorders and describes the course of their treatment. The author posits that such patients fall on a continuum ranging from difficult to treat but still treatable, to those with strong narcissistic or even psychopathic traits whose illness fails to improve no matter what treatment methods are applied (i.e., they have "untreatable" illness).

Screening and prevention.

Abstract:  Glaucoma o Chronic glaucoma is a relatively common disease (1 to 2% of the population in metropolitan France) affecting mainly adults aged over 40, although it can also occur in children or young adults. o It is a serious eye disease, involving the slow destruction of the optic nerve and leading insidiously to a deterioration of the field of vision, with the risk of blindness in the absence of treatment. o It is not accompanied by any pain and detailed vision may be preserved for many years, thus making it impossible for someone to know if he or she is affected by incipient glaucoma. Only a test performed by an ophthalmologist can reveal the presence of this disease. o The exact causes of glaucoma are not yet fully known. There are certain genetically determined factors; thus, the descendants of glaucoma sufferers are more at risk of subsequently developing the disease. o Among the risk factors, the existence of high pressure in the eye is by far the most frequent and significant factor. o In practice, the initial treatment is often a medical treatment consisting of the daily application of one or more drops of hypotonic collyrium in the eye. o This treatment helps to prevent glaucoma from becoming worse for many patients. If this treatment proves to be insufficient (if the visual field continues to deteriorate), laser treatment or surgery may be suggested depending on the patient's age and the severity of the glaucoma.