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Showing papers in "Journal of Psychiatric Practice in 2011"


Journal ArticleDOI
TL;DR: There remains an unmet need for a non-invasive and rapidly acting agent that effectively calms without excessively sedating patients, addresses the patient's underlying psychiatric symptoms, and is reasonably safe and tolerable.
Abstract: Agitation among psychiatric inpatients (particularly those diagnosed with schizophrenia or bipolar disorder) is common and, unless recognized early and managed effectively, can rapidly escalate to potentially dangerous behaviors, including physical violence. Inpatient aggression and violence have su

89 citations


Journal ArticleDOI
TL;DR: This article highlights some of these seemingly incompatible clinical presentations of narcissistic traits and NPD, especially as they co-occur with depressivity and perfectionism, and it discusses implications for building a treatment alliance with a patient with such a predominant disorder of character functioning.
Abstract: Narcissistic traits and narcissistic personality disorder (NPD) present specific diagnostic challenges. While they are often readily and straightforwardly identified, their presentation in some patients and the reasons for which such patients seek treatment may conceal significant narcissistic pathology. Recently, several empirical studies have confirmed that the phenotypic range of people with NPD includes individuals with insecure, shy, and hypersensitive traits with prominent internalized narcissistic features and functioning. Other studies have confirmed that internal emotional distress, interpersonal vulnerability, fear, pain, anxiety, a sense of inadequacy, and depressivity can also co-occur with narcissistic personality functioning. This paper focuses on integrating these findings into the diagnostic evaluation and initial negotiation of treatment for NPD. In patients with narcissistic traits or NPD, it is important to give attention to the two sides of character functioning, which include both self-serving and self-enhancing manifestations as well as hypersensitivity, fluctuations in self-esteem, and internal pain and fragility. This article highlights some of these seemingly incompatible clinical presentations of narcissistic traits and NPD, especially as they co-occur with depressivity and perfectionism, and it discusses implications for building a treatment alliance with a patient with such a predominant disorder of character functioning. The article also discusses the importance of retaining the NPD diagnosis as a separate type of personality disorder, with this range of features, in the upcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DMS-5).

81 citations


Journal ArticleDOI
TL;DR: Preliminary evidence that MBCT may be a treatment option that can be used as an adjunct to medication to improve cognitive functioning in bipolar disorder is provided.
Abstract: Bipolar disorder is associated with impairments in cognition, including difficulties in executive functioning, even when patients are euthymic (neither depressed nor manic). The purpose of this study was to assess changes in self-reported cognitive functioning in patients with bipolar disorder who participated in an open pilot trial of mindfulness-based cognitive therapy (MBCT). Following MBCT, patients reported significant improvements in executive functioning, memory, and ability to initiate and complete tasks, as measured by the Behavior Rating Inventory of Executive Function (BRIEF) and the Frontal Systems Behavior Scale (FrSBe). Changes in cognitive functioning were correlated with increases in mindful, nonjudgmental observance and awareness of thoughts, feelings, and sensations, and were not associated with decreases in depression. Improvements tended to diminish after termination of treatment, but some improvements, particularly those in executive functioning, persisted after 3 months. These results provide preliminary evidence that MBCT may be a treatment option that can be used as an adjunct to medication to improve cognitive functioning in bipolar disorder.

79 citations


Journal ArticleDOI
TL;DR: An overview of the recognition, diagnosis, management, and follow-up of cancer-related PTSD for the mental health clinician is presented.
Abstract: Life-threatening illness has been identified as a stressor that can precipitate posttraumatic stress disorder (PTSD). Major advances in cancer treatment have led to increased survival periods. At the same time, there is a growing awareness of the psychological impact of cancer diagnosis and treatment on the patient. Cancer survivors report that cancer can elicit symptoms of traumatic stress. When cancer-related PTSD is untreated, medical and psychiatric morbidity increase. Despite the prevalence, impact, and morbidity of cancer-related PTSD, access to mental health care in cancer patients remains limited. It is important to increase mental health providers' awareness of cancer-related PTSD, given rising cancer rates and the potential for enhancing quality of life. This article presents an overview of the recognition, diagnosis, management, and follow-up of cancer-related PTSD for the mental health clinician.

54 citations


Journal ArticleDOI
TL;DR: It appears that NEW Tx may be a feasible intervention with promising pilot data for reducing the medical burden in bipolar disorder, but future research is needed to further evaluate the efficacy of New Tx.
Abstract: We developed an integrated psychosocial treatment for bipolar disorder to decrease the disproportionate medical burden associated with this illness. Three treatment modules, Nutrition/weight loss, Exercise, and Wellness Treatment (NEW Tx) were administered in twelve 60-minute group sessions over 14 weeks. After the first group (N=4) had completed the treatment, it was revised, and then a second group (N=6) completed the revised treatment. Participants completed all of the study assessments and attended 82% of the sessions. Both groups added over 100 minutes of weekly exercise to their baseline duration. Participants in the second group showed improvements in their quality of life, depressive symptoms, and weight. It appears that NEW Tx may be a feasible intervention with promising pilot data for reducing the medical burden in bipolar disorder, but future research is needed to further evaluate the efficacy of NEW Tx.

49 citations


Journal ArticleDOI
TL;DR: There was a statistically significant decrease in reporting of crime committed by people with schizophrenia in 2010 compared with 2000, but no significant difference was found in metaphorical usage of the terms schizophrenia and schizophrenic between 2000 and 2010.
Abstract: Newspaper media are a major source of information about mental illness in the United States. Previous research has shown that some printed material has been both negative and stigmatizing, which can have a detrimental impact on individuals with mental illnesses. Such perceptions represented in the media may cause those with mental illnesses to internalize a negative and stigmatizing stereotype and hinder the public's understanding of mental illness. In recent years, advocacy groups have increased their efforts to combat stigmatization of those with mental illnesses. This study focused specifically on the use of stigmatizing language concerning schizophrenia in U.S. newspapers. Because advocacy to decrease stigmatization of mental illness has increased in recent years, this study compared media depictions of schizophrenia in 2000 and 2010 to determine if there had been a reduction in reporting of dangerousness and perpetration of crime by people with schizophrenia or in stigmatizing language. All articles published in five high-circulation newspapers from diverse urban geographical regions between January 1 and June 1 in 2000 and 2010 that contained the words "schizophrenia" or "schizophrenic" were reviewed. Articles were categorized under the categories of education, incidental reference, medical and pharmaceutical news, metaphorical use, charity, obituary, medically inappropriate, and human interest. Human interest articles were further subcategorized into advocacy, crimes committed by people with schizophrenia, crimes committed against those suffering from schizophrenia, and issues related to poor mental health care. There was a statistically significant decrease in reporting of crime committed by people with schizophrenia in 2010 compared with 2000. However, no significant difference was found in metaphorical usage of the terms schizophrenia and schizophrenic between 2000 and 2010.

44 citations


Journal ArticleDOI
TL;DR: Clinicians are encouraged to explore knowledge of appropriate methods of contraception for women who suffer from schizophrenia to be alert for potential interactions among oral hormonal contraceptives, smoking, and therapeutic drugs.
Abstract: Although women with serious mental illness have high rates of lifetime sexual partners, they infrequently use contraception. Consequently, the prevalence of sexually transmitted infections is high in this population. In addition, while the overall rate of pregnancy in women with schizophrenia of child-bearing age is lower than in the general population, the percentage of pregnancies that are unwanted is higher than that in the general population. The objective of this paper is to help clinicians explore knowledge of appropriate methods of contraception for women who suffer from schizophrenia. The authors reviewed recent literature on the use of contraceptive methods by women with schizophrenia treated with antipsychotic and adjunctive medications. Contraceptive counseling to women and their partners is an important part of comprehensive care for women with serious and persistent mental illness. Women with schizophrenia who smoke, are overweight, or have diabetes, migraine, cardiovascular disease, or a family history of breast cancer should be offered non-hormonal contraception. Women with more than one sexual partner should be advised on barrier methods in addition to any other contraceptive measures they are using. Clinicians should be alert for potential interactions among oral hormonal contraceptives, smoking, and therapeutic drugs. Long-lasting contraceptive methods, such as intrauterine devices, progesterone depot injections, or tubal ligation are reasonable options for women having no wish to further expand their families.

40 citations


Journal ArticleDOI
TL;DR: This literature review describes the clinical and empirical evidence indicating that alterations in CYP2D6 activity can negatively affect treatment outcomes in patients receiving antidepressant pharmacotherapies that are CYP 2D6 substrates and proposes a strategy to allow for stratification of treatment outcomes by CYP1D6 metabolizer status.
Abstract: Background. Many currently used antidepressants are substrates of the cytochrome P450 (CYP) 2D6 enzyme. In patients who experience variations in the activity of this enzyme (e.g., CYP2D6 poor and ultrarapid metabolizers [PMs and UMs]), whether caused by genetic polymorphisms or concomitant administr

40 citations


Journal ArticleDOI
TL;DR: The case of a 92-year-old female with major depressive disorder and associated catatonic symptoms and the possible benefits of N-methylD-aspartic acid receptor antagonists such as memantine in the treatment of catatonia are presented.
Abstract: Catatonia is a movement disorder with various possible etiologies. The majority of cases are associated with an underlying mood or psychotic disorder, while others are caused by medical conditions. Currently, benzodiazepines are the first-line psychopharmacologic agents in the treatment of catatonia. However, several cases have been reported in which treatment with memantine proved to be effective. We present the case of a 92-year-old female with major depressive disorder and associated catatonic symptoms. In this case, the patient's symptoms remitted quickly after the initiation of memantine. We review the possible causes of catatonia and pharmacologic treatments for the condition and highlight the possible benefits of N-methylD-aspartic acid receptor antagonists such as memantine in the treatment of catatonia.

34 citations


Journal ArticleDOI
TL;DR: The author examines the various factors that a psychiatrist may consider in making the decision whether or when to retire, which include one's professional persona, the prevailing professional culture, attachment to patients, practice situation, age, health, family situation, finances, other interests, other professional commitments, adaptability, and more.
Abstract: The author examines the various factors that a psychiatrist may consider in making the decision whether or when to retire. These include one’s professional persona, the prevailing professional culture, attachment to patients, practice situation, age, health, family situation, finances, other interests, other professional commitments, adaptability, and more. Personal experience and the limited literature indicate that the prevailing psychiatric professional culture is averse to retirement, but this may vary with changing practice patterns. The decision is a highly individual one that calls for much thought and preparation. This is the first of two articles dealing with retirement. (Journal of Psychiatric Practice 2011;17:351–354)

34 citations


Journal ArticleDOI
TL;DR: The rationale for and initial development of an adjunctive psychosocial intervention that targets adherence in patients with bipolar disorder who are substance abusers are described and results suggest the intervention is feasible and acceptable to patients and could be helpful in enhancing the effects of existing treatments.
Abstract: Patients with comorbid bipolar and substance use disorders are at particularly high risk for treatment nonadherence and a host of negative consequences. However, no previous interventions have been designed specifically to address this problem. In the current study, we describe the rationale for and initial development of an adjunctive psychosocial intervention that targets adherence in patients with bipolar disorder who are substance abusers. The intervention involves brief in-person sessions and follow-up phone contacts with the patient and a significant other/family member. We describe the effects of this novel intervention on adherence and other psychiatric outcomes in a series of cases treated as part of our initial development work. Results suggest that the intervention is feasible and acceptable to patients and could be helpful in enhancing the effects of existing treatments. Given these promising results, we plan to test the intervention further in a randomized clinical trial.

Journal ArticleDOI
TL;DR: Older adults admitted to a geriatric psychiatry ward on a scheduled antipsychotic were commonly prescribed more than one antipsychotics, and patients with a history of a severe mental illness were significantly more likely to have been prescribed antippsychotic polypharmacy.
Abstract: Objectives. This study describes the prevalence of antipsychotic polypharmacy in patients admitted to a geriatric psychiatry unit, compares polypharmacy by psychiatric diagnosis, explores predictors of polypharmacy, and examines changes in antipsychotic polypharmacy from baseline to discharge. Metho


Journal ArticleDOI
TL;DR: Use of L-methylfolate without an additional indication of need does not appear to be warranted in this group of U.S. Caucasians, and an evidence-based approach, such as MTHFR genotyping, should be used to identify these specific patients.
Abstract: Numerous studies have found an association between low serum folate levels and incidence of depression. Folic acid supplementation has been successfully used as an adjunct to treat depression in these patients. However, some individuals have a genetic deficiency in the methylene tetrahydrofolate reductase (MTHFR) gene that limits conversion of folic acid to its biologically active form, L-methylfolate. Several studies have identified a higher frequency of genetic variations in the MTHFR gene in depressed patients than in nondepressed controls. This study evaluated the frequency of the most common genetic variation MTHFR C667T in a group of depressed U.S. Caucasians and compared results with those of a control group of nondepressed U.S. Caucasians. Subjects were recruited from a psychiatric practice, an ambulatory care clinic, and the community. Informed consent and a cheek swab sample were obtained from each subject for analysis using real-time polymerase chain reaction (PCR). Allele and genotype frequencies were compared using Pearson X2 analysis. Complete data were obtained for 156 subjects. No significant differences were found in frequency of the MTHFR C667T T allele (0.415 vs 0.365; p=0.408) or the MTHFR C667T TT genotype (20.7% vs 17.6%; p=0.619) between the depressed and non-depressed controls, respectively. Therefore, use of L-methylfolate without an additional indication of need does not appear to be warranted in this group of U.S. Caucasians. Some patients may benefit from L-methylfolate, but an evidence-based approach, such as MTHFR genotyping, should be used to identify these specific patients. Additional research is also needed to confirm the benefit of L-methylfolate in specific patient populations (e.g., MTHFR TT genotype).

Journal ArticleDOI
TL;DR: The therapeutic benefit of electroconvulsive therapy (ECT), which is usually associated with short-term cognitive impairment, is documented in a 68-year-old woman with psychotic depression whose MMSE and DRS-2 scores initially suggested possible global cognitive impairment and dementia.
Abstract: Major depressive disorder (MDD) with psychotic features is relatively frequent in patients with greater depressive symptom severity and is associated with a poorer course of illness and greater functional impairment than MDD without psychotic features. Multiple studies have found that patients with psychotic mood disorders demonstrate significantly poorer cognitive performance in a variety of areas than those with nonpsychotic mood disorders. The Mini Mental State Examination (MMSE) and the Dementia Rating Scale, Second Edition (DRS-2) are widely used to measure cognitive functions in research on MDD with psychotic features. Established total raw score cut-offs of 24 on the MMSE and 137 on the DRS-2 in published manuals suggest possible global cognitive impairment and dementia, respectively. Limited research is available on these suggested cut-offs for patients with MDD with psychotic features. We document the therapeutic benefit of electroconvulsive therapy (ECT), which is usually associated with short-term cognitive impairment, in a 68-year-old woman with psychotic depression whose MMSE and DRS-2 scores initially suggested possible global cognitive impairment and dementia. Over the course of four ECT treatments, the patient's MMSE scores progressively increased. After the second ECT treatment, the patient no longer met criteria for global cognitive impairment. With each treatment, depression severity, measured by the 24-item Hamilton Rating Scale for Depression, improved sequentially. Thus, the suggested cut-off scores for the MMSE and the DRS-2 in patients with MDD with psychotic features may in some cases produce false-positive indications of dementia.

Journal ArticleDOI
TL;DR: The case of a 79-year-old man who presented with the onset of vivid visual hallucinations after developing cataracts is presented, and previous case reports of CBS are reviewed.
Abstract: Charles Bonnet syndrome (CBS) is a clinical entity in which patients develop vivid visual hallucinations in the absence of psychiatric illness. In the great majority of cases, a decline in visual acuity precedes the development of CBS. The patient maintains intact reality testing and recognizes that the hallucinations are not real. There is no definitive cure for CBS, although various pharmacologic agents, behavioral strategies, and ophthalmologic interventions have been used in an attempt to reduce or relieve symptoms. We present the case of a 79-year-old man who presented with the onset of vivid visual hallucinations after developing cataracts. We also review previous case reports of CBS and discuss treatment options.

Journal ArticleDOI
TL;DR: Although physical restraint may sometimes be necessary to manage aggression and agitation in the emergency department, being restrained appears to be associated with decreased likelihood of attending prescribed outpatient follow-up mental health treatment.
Abstract: While an estimated 8.5% of psychiatric patients treated in emergency departments require physical restraint, the impact of restraint on attendance at post-discharge outpatient psychiatric appointments has not been investigated. This study evaluated two groups of patients aged 18 or over: 1) 67 indiv

Journal ArticleDOI
TL;DR: It is speculated that memory deficits commonly associated with schizophrenia may partly explain why poor insight does not always lead to poor medication adherence among patients with relatively good memory.
Abstract: While lack of insight is often predictive of antipsychotic nonadherence, some inconsistency in the literature remains unexplained. Verbal memory deficits may moderate the association between insight and adherence. Based on cross-sectional data, outpatients treated with antipsychotics for a psychotic disorder were divided into those with good (n = 53) and poor (n = 59) memory. Poor insight predicted nonadherence only among the subgroup with relatively good memory (r = 0.43; p < 0.01), but had no effect in the subgroup with worse memory (r = 0.08; ns). Structural equation modelling revealed significant moderation ( 2 = 4.72; df = 1; p < 0.05), which means that a significantly better model fit was found by allowing the analysis to differentiate between the two memory groups. Thus, poor insight was only associated with poor medication adherence among patients with relatively good memory. We speculate that memory deficits commonly associated with schizophrenia may partly explain why poor insight does not always lead to poor medication adherence.

Journal ArticleDOI
TL;DR: This paper is an attempt to begin a discussion of the process of prescribing medications to patients with BPD and should be considered only the beginning of a dialogue that will surely become more complex and demand increased clinical acumen and more rigorous scientific study as the authors continue to learn more about these complicated and multi-faceted patients.
Abstract: Patients with borderline personality disorder (BPD) are a challenge to treat both psychotherapeutically and psychopharmacologically. While a set of effective psychotherapeutic interventions for BPD has now emerged, no hard evidence exists concerning the effectiveness of any psychopharmacologic agent for the core symptoms of BPD. Nonetheless, more than 75% of patients with BPD regularly take psychotropic medications. Given the complex interpersonal interactions of these patients as well as their obvious psychological pain, it would be helpful if we could begin to discuss the nuts and bolts of prescribing psychotropic medications for patients with BPD with the goal of assisting the psychopharmacologist in this process of prescribing. This paper is an attempt to begin such a discussion of the process of prescribing medications to patients with BPD. The suggestions presented in this article should be considered only the beginning of a dialogue that will surely become more complex and demand increased clinical acumen and more rigorous scientific study as we continue to learn more about these complicated and multi-faceted patients.

Journal ArticleDOI
TL;DR: Subjects switching from quetiapine to ziprasidone showed a small but significant decrease in weight as well as improved lipid profiles, regardless of their metabolic status and disease severity at baseline, and showed improvement in clinical symptoms and in cognitive functioning.
Abstract: ObjectiveThe objectives of this study were to evaluate the effects of switching from quetiapine to ziprasidone on weight, safety, and effectivenessMethodsIn this study, 241 subjects with schizophrenia or schizo affective disorder who had been treated with quetiapine (≥300 mg/day) for ≥3 months with

Journal ArticleDOI
TL;DR: The intervention described here resulted in a reduction in MEs in association with performance improvement efforts that were conducted over 5 years and involved 65,466 patient days, and 617,524 billed doses, which is the largest study of an intervention to reduce psychiatric medication errors reported to date.
Abstract: Medication errors (MEs) in psychiatry have not been extensively studied. No long-term prospective efforts to demonstrate error reduction in psychiatric care using multidisciplinary interventions have been published in the literature. This article discusses the implementation of the Patient Safety Net (PSN) (an error reporting system) and of the Provider Order Entry (POE) program (a prescribing system). We educated and trained staff in their use, conducted concurrent chart reviews to estimate true error reduction, and provided continuous feedback as errors occurred. The intervention described here resulted in a reduction in MEs in association with performance improvement efforts that were conducted over 5 years and involved 65,466 patient days, and 617,524 billed doses, which is the largest study of an intervention to reduce psychiatric medication errors reported to date.

Journal ArticleDOI
TL;DR: Depressed patients with hypothyroidism had more anxiety symptoms and greater agitation, but they had fewer severe core depressive symptoms and biological signs of MDD.
Abstract: Introduction Differentiating major depressive disorder (MDD) without hypothyroidism from MDD associated with hypothyroidism can be challenging. Therefore some authors have suggested that thyroid function should be tested in all depressed patients. This study compared the clinical characteristics of patients with MDD associated with hypothyroidism with those of patients with MDD without hypothyroidism. Method Thyroid function tests were administered to 75 patients (60 female and 15 male) who met DSM-IV criteria for MDD. The 15 patients with hypothyroidism (8 with subclinical hypothyroidism and 7 with overt hypothyroidism) were compared with the other 60 patients with regard to depressive characteristics. The primary measure of depressive signs and symptoms used to assess depression severity and symptoms was the Hamilton Rating Scale for Depression, first 17 items (Ham-D-17). Baseline demographic data, including age and sex, were also compared. Result The two groups did not differ significantly in severity of overall depression at baseline, as measured by total score on the Ham-D-17 (P=0.471, Z=0.970). Patients with MDD without hypothyroidism had worse scores on item 1 (depressed mood), item 2 (feelings of guilt), item 3 (suicidality), item 6 (late insomnia), and item 16 (loss of weight). In contrast, depressed patients with hypothyroidism had more severe anxiety symptoms and greater agitation (items 9, 10, and 11). Conclusion Our results may help clinicians differentiate MDD associated with hypothyroidism from MDD without hypothyroidism. Depressed patients with hypothyroidism had more anxiety symptoms and greater agitation, but they had fewer severe core depressive symptoms and biological signs of MDD. (Journal of Psychiatric Practice. 2011;17:67-71).

Journal ArticleDOI
TL;DR: Primary care physicians must be prepared to adjust, substitute, or augment antidepressant treatments to optimize patient response and enhance the chances of achieving remission.
Abstract: Major depressive disorder (MDD), a highly prevalent psychiatric condition, is encountered in 1 of every 10 to 20 patients seen in the primary care setting. While awareness of MDD has increased, timely and accurate diagnosis and adequate treatment remain formidable challenges. Treatment options for patients with MDD should be individualized according to each patient's clinical and medication history, pharmacologic tolerability profile, and personal preferences, to maximize long-term adherence. The most robust and consistently maintained positive outcomes occur in patients who are administered effective treatment with recommended antidepressant pharmacotherapy, psychotherapy, or a combination of these treatment modalities. This manuscript reviews the epidemiology, biologic and clinical features, diagnosis, and treatment of patients with MDD. A focus is placed on guidelines and strategies that target the achievement of MDD symptom remission. The article also includes details on individualizing treatment selection and novel and emerging therapies. Primary care physicians must be prepared to adjust, substitute, or augment antidepressant treatments to optimize patient response and enhance the chances of achieving remission. Considerations that strongly influence long-term patient adherence, including tolerability and cost, are also reviewed.

Journal ArticleDOI
TL;DR: This column addresses two important clinical trial issues in psychiatry, one of which is the drug-specific response/remission rate and the other, the concept of the placebo response/ Remission rate, which is frequently misrepresented by the media as representing nothing.
Abstract: This column addresses two important clinical trial issues in psychiatry. Placebo is frequently misrepresented by the media as representing nothing. In fact, placebo represents everything except the investigational treatment. That is an important distinction. The second is the concept of the drug-specific response/remission rate. While manufacturers frequently cite the overall response/remission rate observed in the group treated with their drug in their clinical trials, that is not the true rate specifically attributable to the drug. Instead, it represents the combined rate due to both the drug and the non-drug (or "placebo") therapeutic aspects of the trial. To determine the drug-specific response/remission rate, the placebo response/remission rate must be subtracted from the overall response/remission rate observed in the drug treated group. That is because the drug treated group receives both the therapeutic benefit of the drug and all of the nondrug therapeutic benefit of the trial (i.e., the "placebo" condition). Viewed from this perspective, only about one out of four patients with major depression responds specifically to either selective serotonin or serotonin-norepinephrine reuptake inhibitors. These principles are important if one is to put the recent controversy about the effectiveness of modern antidepressant treatment into perspective. The critical issue is not how good the drugs are but rather how serious our diseases are. When evaluating the current antidepressants, the principal issue is not how many patients with major depression they treat but instead how well they treat the patients they do treat. The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study has clearly documented that approximately 40% of patients with major depression do not respond to existing antidepressants. That finding is consistent with the concept that there are likely many forms of depressive illness, only a fraction of which are responsive to drugs that work via effects on biogenic amines.

Journal ArticleDOI
TL;DR: Impairments from ADHD can be chronic and persistent and they can affect daily educational, occupational, and personal functioning so that clinicians need to consider medication duration of action when selecting a pharmacotherapy intervention for adults with ADHD.
Abstract: ObjectiveTo review the literature describing impairments in educational, occupational, and social functioning in adults with attentiondeficit/hyperactivity disorder (ADHD), current treatment trends, and factors that may influence the abuse potential of long-acting medications used to treat ADHD in a

Journal ArticleDOI
TL;DR: A woman with no known medical history presented with catatonia that did not respond to standard treatment with benzodiazepines, suffered a long and complicated hospital course, and was eventually diagnosed with lupus, illustrating the importance of considering medical causes in the diagnosis and treatment of psychiatric disorders, especially the catatonic syndrome.
Abstract: Catatonia is a syndrome of physical and behavioral abnormalities that can result from psychiatric, neurological, or medical illness. Although systemic lupus erythematosus (SLE) is commonly known to cause neurological and psychiatric manifestations, it has only rarely been reported to cause the catatonic syndrome. In nearly all previously reported cases, the diagnosis of catatonia was reported in patients with an established diagnosis of lupus. We report a case in which a woman with no known medical history presented with catatonia that did not respond to standard treatment with benzodiazepines, suffered a long and complicated hospital course, and was eventually diagnosed with lupus. With initiation of treatment for lupus, her symptoms of catatonia remitted. This case illustrates the importance of considering medical causes in the diagnosis and treatment of psychiatric disorders, especially the catatonic syndrome.

Journal ArticleDOI
TL;DR: This column focuses in more detail on limitations of traditional phase I studies for investigating truly novel compounds and proposes solutions to address these problems.
Abstract: In the first part of this series, the authors discussed strengths and weaknesses of traditional phase I drug development involving single ascending dose studies followed by multiple ascending dose studies in healthy volunteers. They then discussed how these traditional designs are being challenged b

Journal ArticleDOI
TL;DR: The authors are at the beginning of an era when it is likely that the way in which CNS drugs are developed will need to be rethought, which will call for flexibility and creativity on the part of both drug developers and clinical researchers.
Abstract: This column, the third in a series on central nervous system (CNS) drug development, discusses advances during the first decade of the 21st century and directions the field may take in the next 10 years. By identifying many possible new drug targets, the human genome project has created the potential to develop novel central nervous system (CNS) drugs with new mechanisms of action. At the same time, this proliferation of possible new targets has complicated the drug development process, since research has not yet provided guidance as to which targets may be most fruitful. This and other factors (eg, increasing regulatory requirements) have increased the cost and complexity of the drug development process. In addition, as more is learned about the biology of psychiatric illnesses, syndromes may be subdivided into more specific entities that are better understood from a pathophysiological and pathoetiological perspective. This is likely to lead to development of more targeted treatments focused on underlying causes of illness as well as prevention. The development of drugs for Alzheimer's disease is discussed as a possible model for future CNS drug development. We are at the beginning of an era when it is likely that the way in which CNS drugs are developed will need to be rethought, which will call for flexibility and creativity on the part of both drug developers and clinical researchers.

Journal ArticleDOI
TL;DR: The implementation of this educational program was correlated with increasing use of generic medications and brought antipsychotic prescribing into concordance with the new evidence, and has implications for promoting cost-effective care while preserving patient choice in the mental health system.
Abstract: OBJECTIVE Recent clinical trials comparing the effectiveness of antipsychotics have found no advantage for second-generation antipsychotics over older first-generation agents. However, the former are much more commonly used despite their significantly higher cost and potential for contributing to the metabolic syndrome. To date, educational interventions have been unsuccessful in influencing this pattern. The Duke University Medical Center Department of Psy chiatry began a program based on principles of academic detailing designed to educate psychiatry residents about generic psychotropics. To encourage residents to gain experience with these medications, samples of selected generic drugs were provided. To assess the initiative's impact, the authors measured the prescribing patterns of residents. METHODS We measured the amount of generic drug use 6 months after the program began and compared it with data from a 6-month control period. The data were analyzed based on overall psychotropic use, class of medication, site, and diagnosis. RESULTS We found a consistent increase in generic use across analyses. There was an increase in overall generic prescribing from 55.8% to 58.6% [X=10.37, odds ratio (OR)=1.12, P=0.0013] and a particularly large increase in prescribing of generic antipsychotic medications from 39.5% to 47.7% [X=36.12, OR=1.39, P<0.0001]. Conclusion. The implementation of this educational program was correlated with increasing use of generic medications and brought antipsychotic prescribing into concordance with the new evidence. This is the first such study in a psychiatry residency program and has implications for promoting cost-effective care while preserving patient choice in the mental health system. The findings from this study also suggest potential techniques for expanding residents' prescribing skills across specialties.

Journal ArticleDOI
TL;DR: The application of this proposed treatment algorithm allows for more accurate identification of true treatment resistance and can significantly reduce manic symptoms in patients previously described as having treatment-refractory bipolar disorder.
Abstract: OBJECTIVE To implement a treatment algorithm to operationalize treatment-resistance and improve patient outcomes in youth with pediatric bipolar disorder (PBD). The term "treatment resistance" was operationally defined as significant persistent symptoms following the application of a treatment algorithm. METHOD Youth (6-17 years of age, n=120) with treatment-refractory bipolar I or II disorder, currently in a manic or mixed episode, were treated in accordance with the following 3 step algorithm: (1) removal of destabilizing agents (antidepressants, gamma aminobutyric acid [GABA]-agonists, and stimulants), (2) optimization of antimanic agents, and (3) use of a limited number (E 2) of mood stabilizers. The primary efficacy measure was change in scores on the Young Mania Rating Scale (YMRS) over the 6-month treatment course. Response was defined as repeated YMRS scores E 12. RESULTS The sample was dichotomized into responders and non-responders. Both responders and non-responders improved significantly, with responders improving by a greater margin (d=3.2). At the end of 6 months, 75.8% of subjects demonstrated a significant and stable decrease in manic symptoms consistent with symptomatic remission (YMRS E 12). None of the subjects withdrew from the clinical process due to adverse events. CONCLUSION The application of this proposed treatment algorithm allows for more accurate identification of true treatment resistance and can significantly reduce manic symptoms in patients previously described as having treatment-refractory bipolar disorder.