Wednesday, December 2, 2009

Clozapine for schizophrenia: Life-threatening or life-saving treatment?


Leslie Citrome, MD, MPH, Professor of psychiatry, New York University School of Medicine, New York, NY, Director, Clinical Research and Evaluation Facility, Nathan S. Kline Institute for Psychiatric Research, Orangeburg, NY

Researchers in Finland surprised psychiatrists this year by announcing that clozapine “seems to be associated with a substantially lower mortality than any other antipsychotic.” This finding also surprised the researchers, who expected their 11-year study to link long-term use of second-generation (“atypical”) antipsychotics with increased mortality in patients with schizophrenia. Instead they found longer lives in patients who used antipsychotics (and particularly clozapine), compared with no antipsychotic use.

This study’s findings do not change clozapine’s association with potentially fatal agranulocytosis as well as weight gain, metabolic abnormalities, and other adverse effects. Clozapine also is difficult to administer, and patients must be enrolled in FDA-mandated registries. These obstacles might discourage you from offering clozapine to patients who could benefit from it.

Why bother considering clozapine? Because recent data on decreased mortality, decreased suicidality, and control of aggressive behavior make clozapine a compelling choice for many patients. Careful attention to clozapine’s adverse effect profile is necessary, but you can manage these risks with appropriate monitoring.

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Late-life depression: Managing mood in patients with vascular disease


Helen Lavretsky, MD, MS,
Associate professor of psychiatry, Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine at UCLA, Los Angeles, CA


Thomas Meeks, MD, Assistant professor of psychiatry, Division of geriatric psychiatry, VA San Diego Healthcare System, Sam and Rose Stein Institute for Research on Aging, University of California, San Diego

Newly diagnosed major depressive disorder (MDD) in patients age ≥65 often has a vascular component. Concomitant cerebrovascular disease (CVD) does not substantially alter the management of late-life depression, but it may affect presenting symptoms, complicate the diagnosis, and influence treatment outcomes.

The relationship between depression and CVD progression remains to be fully explained, and no disease-specific interventions exist to address vascular depression’s pathophysiology. When planning treatment, however, one can draw inferences from existing studies. This article reviews the evidence on late-life depression accompanied by CVD and vascular risk factors, the “vascular depression” concept, and approaches to primary and secondary prevention and treatment.

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Mindfulness interventions for depression and anxiety


Mark A. Lau, PhD, RPsych, Clinical associate professor, Department of psychiatry, University of British Columbia, Vancouver, BC, Canada

Andrea D. Grabovac, MD, FRCPC, Clinical assistant professor, Department of psychiatry, University of British Columbia, Vancouver, BC, Canada


Mindfulness-based cognitive therapy (MBCT) was originally developed to help prevent depressive relapse. MBCT also can reduce depression and anxiety symptoms. More recently, MBCT was shown to help individuals discontinue antidepressants after recovering from depression. Regular mindfulness meditation has been shown to result in structural brain changes that may help explain how the practice effectively addresses psychiatric symptoms. With appropriate training, psychiatrists can help patients reap the benefits of this cognitive treatment.

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Are psychiatrists more evidence-based than psychologists?


Henry A. Nasrallah, MD
Editor-in-Chief


A recent psychology journal article lambasted clinical psychologists for not using evidence-based psychotherapeutic modalities when treating their patients. The authors pointed out that many psychologists were ignoring efficacious and cost-effective psychotherapy interventions or using approaches that lack sufficient evidence.

An accompanying editorial was equally scathing—calling the disconnect between clinical psychology practice and advances in psychological science “an unconscionable embarrassment”—and warned that the profession “will increasingly discredit and marginalize itself” if it persists in neglecting evidence-based practices. The author quoted the respected late psychologist Paul Meehl as saying “most clinical psychologists select their methods like kids make choices in a candy store” and added that the comment is heart-breaking because it is true. A Newsweek column—“Ignoring the evidence: Why do psychologists reject science?”—elicited little agreement and mostly howls of protest from psychologists.

So, are psychiatrists more evidence-based than psychologists?

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Wednesday, November 4, 2009

Testifying for civil commitment


B. Todd Thatcher, DO, Forensic psychiatrist, Valley Mental Health Forensic Unit, Salt Lake City, UT

Douglas Mossman, MD, Director, Glenn M. Weaver Institute of Law and Psychiatry, University of Cincinnati College of Law, Director, Forensic Psychiatry Fellowship, University of Cincinnati College of Medicine, Cincinnati, OH

Testifying in civil commitment proceedings sometimes is the only way to make sure dangerous patients get the hospital care they need. But for many psychiatrists, providing courtroom testimony can be a nerve-wracking experience because they:

•lack formal training about how to testify
•lack familiarity with laws and court procedures
•fear cross-examination.

Training programs are required to teach psychiatry residents about civil commitment but not about how to testify. Residents who get to take the stand during training usually do not receive any instruction. Knowing some fundamentals of testifying can reduce your anxiety and reluctance to take the stand and help you to perform better in court.

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Tuesday, November 3, 2009

New algorithm for pediatric bipolar mania


Robert A. Kowatch, MD, PhD, Professor of psychiatry and pediatrics, Director of psychiatry research, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH

Jeffrey R. Strawn, MD
, Clinical fellow, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH

Michael T. Sorter, MD, Associate professor of psychiatry and pediatrics, Director, division of psychiatry, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH

Five recent randomized controlled trials (RCTs) have demonstrated the efficacy of atypical antipsychotics for treating bipolar disorder in children and adolescents, but 4 of these 5 trials remain unpublished. The lag time between the completion of these trials and publication of their results—typically 4 to 5 years—leaves psychiatrists without important evidence to explain to families and critics why they might recommend using these powerful medications in children with mental illness.

This article previews the preliminary results of these 5 RCTs of atypical antipsychotics, offers a treatment algorithm supported by this evidence, and discusses how to manage potentially serious risks when using antipsychotics to treat children and adolescents with bipolar disorder (BPD).


Do psychiatrists support the public option?




Henry A. Nasrallah, MD
Editor-in-Chief


Like everyone else, I could not avoid being swept up by the national debate about how to reform our health care system. The debate has been highly politicized, with the liberal left strongly supporting and the conservative right vehemently opposing a single-payer government-run public option (but keeping Medicare and Medicaid). Independents seem to waver between the major overhaul of a public option and making the system more competitive and less expensive.

So I started thinking: where do U.S. psychiatrists stand on a public health care option? I decided to formulate a hypothesis and test it by polling a sample of Current Psychiatry readers. My hypothesis: A substantial proportion (>60%) of practicing U.S. psychiatrists favor a single-payer public option. My rationale: My hunch was that what we psychiatrists deal with in clinical practice may shape and predict how we think about health care, irrespective of our politics.

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Friday, October 2, 2009

Pharmacologic treatment of sex offenders


Bradley D. Booth, MD, Assistant professor, Department of psychiatry, Director of education, Integrated Forensics Program, University of Ottawa, Ottawa, ON, Canada

Sex offenders traditionally are managed by the criminal justice system, but psychiatrists are frequently called on to assess and treat these individuals. Part of the reason is the overlap of paraphilias (disorders of sexual preference) and sexual offending. Many sexual offenders do not meet DSM criteria for paraphilias, however, and individuals with paraphilias do not necessarily commit offenses or come into contact with the legal system.

As clinicians, we may need to assess and treat a wide range of sexual issues, from persons with paraphilias who are self-referred and have no legal involvement, to recurrent sexual offenders who are at a high risk of repeat offending. Successfully managing sex offenders includes psychological and pharmacologic interventions and possibly incarceration and post-incarceration surveillance. This article focuses on pharmacologic interventions for male sexual offenders.


Thursday, October 1, 2009

CAM for patients with depression


Sy Atezaz Saeed, MD, Professor and chair, Department of psychiatric medicine, Brody School of Medicine at East Carolina University, Greenville, NC

Richard M. Bloch, PhD, Professor and director of research, Department of psychiatric medicine, Brody School of Medicine at East Carolina University, Greenville, NC

Diana J. Antonacci, MD, Associate professor and director of residency training, Department of psychiatric medicine, Brody School of Medicine at East Carolina University, Greenville, NC

C. Ervin Davis, III, PhD, Assistant professor, department of psychology, Adjunct assistant professor of psychiatry, Department of psychiatric medicine, Brody School of Medicine at East Carolina University, Greenville, NC

Crystal Manuel, MD, Assistant professor, Department of psychiatric medicine, Brody School of Medicine at East Carolina University, Greenville, NC

Americans with depression turn to complementary and alternative medicine (CAM) more often than conventional psychotherapy or FDA-approved medication. In a nationally representative sample, 54% of respondents with self-reported “severe depression”—including two-thirds of those receiving conventional therapies—reported using CAM during the previous 12 months.

Unfortunately, popular acceptance of CAM for depression is disproportionate to the evidence base, which—although growing—remains limited. As a result, your patients may be self-medicating with poorly supported treatments that are unlikely to help them recover from depression.

In reviewing CAM treatments for depression, we found some with enough evidence of positive effect that we feel comfortable recommending them as evidence-based options. These promising, short-term treatments are supported by level 1a or 1b evidence and at least 1 study that demonstrates an ability to induce remission.





STEPPS for patients with borderline personality disorder


Donald W. Black, MD, Professor, Department of psychiatry, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA

Nancee Blum, MSW, Adjunct instructor, Department of psychiatry, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA

Don St. John, MA, PA-C, Physician assistant, Department of psychiatry, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA

Treatment of borderline personality disorder (BPD) often is viewed as challenging and the results so discouraging that some clinicians avoid referrals of BPD patients. Psychotherapy has been the treatment mainstay for decades, and supportive approaches are probably the most widely employed. Psychodynamic therapy often has been recommended.

This article introduces a new evidence-based group treatment program that we developed for BPD patients. Systems Training for Emotional Predictability and Problem Solving (STEPPS) is founded on the successes of better known psychoeducational models but is easier for practicing psychiatrists to implement.

Does psychiatric practice make us wise?


Henry A. Nasrallah, MD
Editor-in-Chief

At a recent morning rounds, a resident presented a case of a do-not-resuscitate decision for an elderly patient, which our psychiatry consultation service received overnight from an internal medicine ward. Another resident casually mentioned how physicians from other services at our hospital habitually call on psychiatrists to “make the difficult ethical decisions for them.”

That got me thinking. Psychiatrists are expected to analyze conflicts, resolve dilemmas, exercise good judgment, provide advice to colleagues and patients, and display a transcendent and objective perspective about the complexities of life. Psychiatric training and practice prompt us to be thoughtful, tolerant of ambiguity, and willing to tackle the multilayered meanings and consequences of human behavior. Indeed, developing attributes related to the most advanced functions of the human mind is at the core of our professional training and clinical practice.

Wednesday, September 2, 2009

Transcend dread: 8 ways to transform your care of ‘difficult’ patients


John
Battaglia, MD
Medical director, Program of assertive community treatment, Clinical associate professor, Department of psychiatry, University of Wisconsin, Madison, WI

Although “the difficult patient” is not a diagnosis or specific clinical entity, clinicians universally struggle with such patients and have an immediate sense of shared experience when describing the phenomenon. In primary care, O’Dowd aptly described this type of patient as the “heartsink” patient, meaning the practitioner often feels exasperation, defeat, or dislike when he or she sees the patient’s name on the schedule.

This article discusses the literature on this topic and provides strategies for dealing with difficult patients in psychiatric practice.

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Help your bipolar disorder patients remain employed


Charles
L. Bowden, MD
Clinical professor of psychiatry and pharmacology, Nancy U. Karren Distinguished Chair of Psychiatry, The University of Texas Health Science Center at San Antonio

Bipolar disorder’s long-term course presents a therapeutic challenge when patients desire to remain employed, seek temporary or permanent disability status, or—most commonly—attempt to return to employment after a period of inability to work. As the experience of Mrs. S illustrates, previous capabilities that appear higher than the person’s present or recent work experience are a key issue to address in interpersonal therapy.

Evidence-based research is informative, but ultimately you must apply judgment and flexibility in setting and revising goals with the bipolar individual. Attention to the disorder’s core characteristics can help you equip patients for work that contributes to their pursuit of health.

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Dissociative identity disorder: Time to remove it from DSM-V?


Numan
Gharaibeh, MD
Staff psychiatrist, Department of psychiatry, Danbury Hospital, Danbury, CT

Dr. Gharaibeh is a an attending psychiatrist on the inpatient unit at Danbury Hospital in Danbury, CT. He teaches psychiatric residents from New York Medical College during their rotation in Danbury Hospital and physician assistant students from Quinnipiac University, Hamden, CT.

What is it about dissociative identity disorder (DID) that makes it a polarizing diagnosis? Why does it split professionals into believers and nonbelievers, stirring up heated debates, high emotions, and fervor similar to what we see in religion?

The DID controversy is likely to continue beyond the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), slated for publication in 2012. Proponents and opponents claim to have the upper hand in arguments about the validity of the DID diagnosis and benefits vs harm of treatment. This article examines the logic of previous and new arguments.

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Paradigms shift rapidly in antipsychotic treatment


Henry A. Nasrallah, MD
Editor-in-Chief

Like the “paradigm shift” Thomas Kuhn coined in his seminal book, The Structure of Scientific Revolutions, paradigm shifts have been occurring at a breathless pace in psychiatry. Thanks to ongoing research, changes in the clinical standard of care for schizophrenia in the past 20 years are a case in point.

Let’s take 1988 as a starting point. That’s when clozapine was “resurrected” as the only drug with proven efficacy in refractory schizophrenia after several first-generation antipsychotics (FGAs) had been tried. However, because of its potentially fatal side effect (agranulocytosis), clozapine was designated as an absolute last-resort agent. It also was stigmatized for its many other side effects, including serious metabolic complications.

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Monday, August 3, 2009

Life after near death: What interventions works for a suicide survivor?


Sarah M. Jacobs, MEd

Fourth-year medical student, Mayo Medical School, Rochester, MN

J. Michael Bostwick, MD
Associate professor of psychiatry, Mayo Clinic College of Medicine, Rochester, MN


Completed suicide provokes a multitude of questions: What motivated it? What interventions could have diverted it? Could anyone or anything have prevented it? The question of who dies by suicide often overshadows the question of what lessons suicide attempt (SA) survivors can teach us. Their story does not end with the attempt episode. For these patients, we have ongoing opportunities for interventions to make a difference.

A history of SA strongly predicts eventual completion, so we must try to identify which survivors will reattempt and complete suicide. This article addresses what is known about the psychiatry of suicide survivors—suicide motives and methods, clinical management, and short- and long-term outcomes—from the perspective that suicidality in this population may be a trait, with SA or deliberate self-harm (DSH) as its state-driven manifestations. When viewed in this manner, it is not just a question of who survives a suicide attempt, but who survives suicidality
.

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Listen to Dr. Bostwick explain how the 'script' of your patient's suicide attempt can help you plan effective treatment


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Is a medical illness causing your patient's depression?


Virginia K. Carroll, MD

Fifth-year resident, Departments of psychiatry and internal medicine, Rush University Medical Center, Chicago, IL

Jeffrey T. Rado, MD
Assistant Professor, Departments of psychiatry and internal medicine, Rush University Medical Center, Chicago, IL


A patient who comes to you for treatment of depression might also present with physical symptoms (such as, fatigue, nausea, balance problems, etc.) that could point to a medical illness. Endocrine, neurologic, infectious, and malignant processes and vitamin deficiencies could be causing your patient’s depression. To help differentiate various etiologies of depressive symptoms, we review common medical causes of depression, their distinguishing characteristics, and pertinent treatment issues.

DSM-IV-TR considers major depression secondary to a general medical condition to be diagnostically separate from a major depressive episode. When considering nonpsychiatric causes of depression, begin with a thorough medical history including current and past medications, illicit substance use, review of systems, and a detailed neurologic exam.

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How to reduce distress and repetitive behaviors in patients with OCD


Elna Yadin, PhD

Research associate, Center for Treatment and Study of Anxiety, Department of psychiatry, University of Pennsylvania, Philadelphia, PA

Edna B. Foa, PhD
Professor and director, Center for Treatment and Study of Anxiety, Department of psychiatry, University of Pennsylvania, Philadelphia, PA


Exposure and response (or ritual) prevention has been shown to be effective in improving the therapeutic outlook for patients with obsessive-compulsive disorder (OCD). Yet barriers—including patient unwillingness to enter into the intensive therapy—prevent more persons with OCD from achieving an improved quality of life.

This article focuses on the clinical picture of OCD and the multifaceted cognitive-behavioral therapy (CBT) that has received the most empirical support. We also describe initiatives to make CBT more accessible to OCD patients, such as providing twice-weekly instead of daily treatment sessions.

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Let me tell you how I feel… (Things that nag at me)



Henry A. Nasrallah, MD

Editor-in-Chief

Every psychiatrist and mental health professional encourages patients to “express your feelings.” Venting produces a cathartic effect, especially if frustrations have been harbored for a while. So I thought I should practice what I preach and tell you some things that annoy me about the contemporary state of psychiatry, which might bother some of you as well.

Why have we allowed our patients to be relocated from hospitals to jails and prisons? How were the mentally ill transformed from “patients” to “felons?” State hospitals have been shuttered, but correctional facilities are a growth industry.

Why have community-based mentally ill patients become “clients,” as if mental healthcare was a business transaction? Would cardiologists or oncologists accept labeling their patients as “clients?” No chance!


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Wednesday, July 1, 2009

Soft bipolarity: How to recognize and treat
bipolar II disorder


Daniel J. Smith, MD, MRCPsych

Clinical senior lecturer in psychiatry, Cardiff University School of Medicine, Cardiff, UK

At least 25% and possibly up to 50% of patients with recurrent major depressive disorder (MDD) have features of mild hypomania (the “soft end” of the bipolar spectrum) and might be better conceptualized as suffering from a broadly defined bipolar (BP) II disorder. The challenge is to differentiate MDD from BP II so that we make treatment decisions—such as antidepressants vs mood stabilizers—shown to improve the long-term course of patients’ depressive symptoms.

Diagnosis of BP II often is not straightforward and unfortunately may be delayed several years after patients first present for evaluation. To help clinicians make correct diagnostic decisions, this article:
  • describes diagnostic criteria outside of DSM-IV-TR that can assist in identifying BP II disorder
  • identifies subgroups of recurrently depressed patients whose primary disorder is more likely to be bipolar than unipolar
  • provides a screening tool validated for identifying “soft” bipolarity
  • offers a pragmatic clinical perspective on the treatment of BP II disorder.

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Listen to Dr. Smith offer tips on differentiating bipolar II and borderline personality disorder

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Assessing potential for harm:
Would your patient injure himself or others?


Charles Scott, MD

Professor of clinical psychiatry, Chief, division of psychiatry and the law, Department of psychiatry and behavioral sciences, University of California, Davis School of Medicine, Sacramento, CA

Phillip J. Resnick, MD
Professor of psychiatry, Director, division of forensic psychiatry, Case Western Reserve University, Cleveland, OH

Police take Ms. L, age 23, to the emergency room (ER) after her fiancĂ© called them. He told the police that after a “night of drinking” they argued about a girl he had flirted with. Ms. L took out a loaded gun and threatened to shoot herself. She eventually handed the gun over to the police.

In the ER, Ms. L’s blood alcohol level is 0.20%. She tells the admitting emergency room nurse, “I would never hurt myself. I drank too much and was acting stupid. I just want to go home and sleep it off. I promise not to harm myself.” Emergency room staff observe Ms. L smile and giggle while waiting for a psychiatric evaluation.

What would you do? Hospitalize Ms. L for safety, or accept her promise not to hurt herself and send her home? What criteria would you use?

Knowing how to assess patients such as Ms. L is an essential psychiatric skill, whether or not you trained in forensic psychiatry. This article includes case reports that illustrate techniques for evaluating patients who may harbor suicidal or homicidal thoughts.


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Choosing antipsychotics for children
with schizophrenia


Jean A. Frazier, MD

Robert M. and Shirley S. Siff Chair and professor of psychiatry and pediatrics, and vice chair and director, division of child and adolescent psychiatry, University of Massachusetts Medical School, Worcester, MA

Robert A. Kowatch, MD, PhD
Section Editor for Current Psychiatry and professor of psychiatry and pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH.

Jean A. Frazier, MD was 1 of 4 principal investigators in the Treatment of Early-Onset Schizophrenia Spectrum Disorders (TEOSS) study, a randomized, double-blind, multisite trial funded by the National Institute of Mental Health. The study, published in November 2008, compared the efficacy and tolerability of 3 antipsychotics—olanzapine, risperidone, and molindone—in pediatric patients with schizophrenia or schizoaffective disorder.

Dr. Frazier discusses the unexpected findings of the TEOSS trial with Current Psychiatry Section Editor Robert A. Kowatch, MD, PhD. Based on the trial findings and her experience, she tells how she makes decisions when prescribing antipsychotics for children and adolescents with schizophrenia and related disorders.


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The $1.2 billion CME crisis: Can eleemosynary replace industry support?



Henry A. Nasrallah, MD

Editor-in-Chief

Change is coming for continuing medical education (CME). A cloud of conflict of interest has shrouded any person or activity that receives pharmaceutical funding, including the venerable institution of CME. This is a big deal because all health practitioners rely on CME programs to meet requirements for license renewal and to keep up with medical advances.

Attitudes about commercial support of CME have changed, with some organizations calling for elimination of all industry funding. Pressure to strip commercial support from CME is equivalent to draining blood from a living organism; it can have dire consequences if done precipitously.


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Monday, June 1, 2009

Exercise prescription: A practical, effective therapy for depression


Kanwaldeep S. Sidhu, MD

Fourth-year resident, Department of psychiatry and behavioral neurosciences, Wayne State University, Detroit, MI

Pankhuree Vandana, MD
Third-year resident, Department of psychiatry and behavioral neurosciences, Wayne State University, Detroit, MI

Richard Balon, MD
Professor, Department of psychiatry and behavioral neurosciences, Wayne State University, Detroit, MI


Antidepressants alone do not adequately treat many patients with depression. In the STAR*D Project—which compared long-term outcomes of various depression treatments—only 28% to 33% of outpatients achieved remission with selective serotonin reuptake inhibitor (SSRI) monotherapy. Rates were somewhat higher with bupropion or serotonin norepinephrine reuptake inhibitor (SNRI) monotherapy, but greater benefit was obtained from augmenting SSRIs.

Combining antidepressants with psychotherapy and lifestyle changes—particularly exercise—makes sense intuitively and is supported by well-designed studies. This article examines the evidence supporting exercise for treating and preventing clinical depression. We begin by addressing clinicians’ concerns about motivating depressed patients to exercise.

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Listen to Kanwaldeep S. Sidhu, MD, offer advice on talking to patients about exercise

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Weight gain with antipsychotics: What role does leptin play?


Hua Jin, MD

Associate clinical professor, Department of psychiatry, University of California, San Diego VA San Diego Healthcare System, San Diego, CA

Jonathan M. Meyer, MD
Assistant professor, Department of psychiatry, University of California, San Diego VA San Diego Healthcare System, San Diego, CA


Clinical studies indicate that clozapine and olanzapine carry a high risk of treatment-related metabolic dysfunction—including weight gain, hyperlipidemia, and glucose intolerance—but certain patients with high metabolic liabilities who take atypical antipsychotics do not necessarily develop these adverse effects. Though the underlying mechanism for atypical antipsychotic-related weight gain is strongly associated with central histamine H1 antagonism and increased appetite, the pharmacologic basis for other metabolic changes is not fully understood and may involve weight-independent mechanisms.

One potentially relevant research area is peptide hormones’ impact on the regulation of food intake, body weight, and other metabolic parameters. As research has elucidated the properties of 1 of these hormones—leptin—investigators have started to examine possible correlations between changes in serum levels of leptin and weight gain during atypical anti-psychotic treatment.

This article summarizes available clinical data on the interaction of atypical antipsychotics with leptin and indicates directions for future research on interactions between psychotropic medications and metabolic hormones.

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Alcohol dependence in women: Comorbidities can complicate treatment

Rebecca A. Payne, MD
Fourth-year resident, Department of psychiatry and behavioral sciences, Medical University of South Carolina, Charleston, SC

Sudie E. Back, PhD
Associate professor, Department of psychiatry and behavioral sciences, Medical University of South Carolina, Charleston, SC

Tara Wright, MD
Assistant professor, Department of psychiatry and behavioral sciences, Medical University of South Carolina, Charleston, SC

Karen Hartwell, MD
Instructor, Department of psychiatry and behavioral sciences, Medical University of South Carolina, Charleston, SC

Kathleen T. Brady, MD, PhD
Professor of psychiatry, Director, clinical neuroscience division, Department of psychiatry and behavioral sciences, Medical University of South Carolina, Charleston, SC


For years, little was known about alcohol use and alcohol-related problems in women. Alcohol dependence studies rarely included women, so findings and treatment outcomes observed in men were assumed to apply to both genders.

Awareness of gender differences in addiction has grown. Biological and psychosocial differences between alcohol-dependent women and men now are understood to influence etiology, epidemiology, psychiatric and medical comorbidity, course of illness, and treatment outcomes. This article discusses recent insights into planning treatment to address specific needs of alcohol-dependent women.

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Is psychiatry in a recession?



Henry A. Nasrallah, MD

Editor-in-Chief

During this economic recession, it feels as if the entire country is suffering from an “adjustment disorder with anxiety and dysphoria.” I don’t want to depress you further, but doesn’t it seem that psychiatry is having its own recession, reflected in our profession’s collective psyche?

Despite breathtaking discoveries in neuroscience, clinical advances are stalling because of a “perfect storm” of setbacks for our profession.


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Friday, May 1, 2009

Economic anxiety: First aid for the recession’s casualties


Christopher Palmer, MD

Medical director, Continuing medical education, McLean Hospital, Belmont, MA, Harvard Medical School

Jeffrey Rediger, MD, MDiv
Medical director, Adult inpatient service, McLean Hospital, Belmont, MA, Harvard Medical School

Carol Kauffman, PhD, ABPP, PCC
Director, Institute of Coaching, McLean Hospital, Belmont, MA, Harvard Medical School


How is the recession affecting psychiatric practice? Christopher Palmer, MD, says, “We in psychiatry and psychology are well-equipped to help people who are unemployed, underemployed, and financially ruined. We do it all the time. The difference in this economy is that we’re going to be seeing a lot more people.”

Psychiatrists who read Current Psychiatry and were polled in March 2009 agree. Most were seeing an increase in patients experiencing psychological stress because of the recession, which by then had persisted 16 months. “All my patients are reporting increased stress as a result of the economic situation. The more successful my patient is, the more distress they seem to be feeling,” says a psychiatrist from Melbourne, FL.

This article on the psychological effects of the recession discusses the results of an online survey of Current Psychiatry readers, with analysis and recommendations from an interview with Dr. Palmer and colleagues Jeffrey Rediger, MD, MDiv, and Carol Kauffman, PhD, ABPP, PCC, from McLean Hospital, Belmont, MA, and the department of psychiatry, Harvard Medical School.

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Risk factors for suicide in borderline personality disorder


Michele S. Berk, PhD
Assistant professor of psychiatry, David Geffen School of Medicine at UCLA, Harbor-UCLA Medical Center, Torrance, CA

Bernadette Grosjean, MD
Assistant professor of psychiatry, David Geffen School of Medicine at UCLA, Harbor-UCLA Medical Center, Torrance, CA

Heather D. Warnick, PsyD
Postdoctoral Fellow, Harbor-UCLA Medical Center, Torrance, CA


Manipulative, “just threats,” or suicide gestures are terms you may have heard or used to label suicidal thoughts and behavior in individuals with borderline personality disorder (BPD). These terms imply that the risk of injury or death is low, but evidence shows that BPD patients are at high risk for completed suicide—and clinicians who use these labels may underestimate this risk and respond inadequately.

Based on the literature and our clinical experience, this article offers recommendations for assessing and treating suicidal behavior in BPD patients. We review risk factors for suicide and suicide attempts and suggest strategies for safety management, psychotherapy, and pharmacotherapy. Because of the high-risk nature of this population, we recommend that all clinicians working with suicidal BPD patients obtain consultation and supervision as needed when using these strategies.

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What is your patient’s predicament?


Daniel D. Cowell, MD

Senior associate dean for graduate medical education, Professor of psychiatry, Department of psychiatry and behavioral medicine, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV


When a patient’s symptoms seem disproportionate to apparent stressors, I call this presentation a patient’s predicament: a unique, profoundly unsettling, but poorly understood misgiving that something is wrong—perhaps terribly so—and that life may never be the same again. Emotional flooding typically overwhelms these patients, and they are unable to express what they are experiencing.

For mental health professionals, the concept of a predicament is useful when working with patients who are moderately to severely ill or facing a life-diminishing or life-threatening illness.

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The hallucination portrait of psychosis: Probing the voices within



Henry A. Nasrallah, MD

Editor-in-Chief

On recent hospital rounds with residents and medical students, a medical student presented a 20-year-old man with first-episode psychosis. The student mentioned that the patient admitted to hearing voices, and the admission note in the patient’s chart referred simply to “AH+” (auditory hallucinations present)

I was disappointed. This sparse description of a key psychotic symptom ignored rich details that could provide important clinical and safety information about the patient. So I suggested that the students and residents ask this patient many more questions about his AH.

In my experience, clinicians rarely retrieve and document the wealth of data available about AHs when assessing persons with psychosis. I recommend that clinicians include such details in the initial mental status exam of a patient with psychosis.

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Wednesday, April 1, 2009

Clinical guide to countertransference: Help medical colleagues deal with ‘difficult’ patients


Philip R. Muskin, MD
Professor of clinical psychiatry, Columbia University College of Physicians and Surgeons, Chief, Consultation-liaison psychiatry, Columbia University Medical Center, Faculty, Columbia University Psychoanalytic Center for Training and Research, New York, NY

Lucy A. Epstein, MD
Postdoctoral clinical fellow in psychosomatic medicine, Columbia University College of Physicians and Surgeons, New York, NY


Two strangers meet in the hospital cafeteria. Mrs. R, an elderly woman, asks Dr. W, a first-year medical resident, for help in getting a bottle of soda from the cooler. Afterward, Dr. W comments to a colleague with whom she is having lunch, “That woman reminds me of my grandmother.”

What does that comment reflect about Dr. W? It is a statement about the doctor’s transference. That is, she is aware of elements about Mrs. R that evoke internal responses appropriate to a prior important relationship.

What if Mrs. R was to subsequently faint, require admission to the hospital, and become Dr. W’s patient? If Dr. W’s comment indicates transference, would the same reaction to Mrs. R now be countertransference? Does that change if the doctor is unaware of emotions Mrs. R evokes? Is it still countertransference whether Dr. W is caring and compassionate, overly involved with Mrs. R, or—unaware of negative feelings associated with “grandmothers”—avoids the patient?

This article explores how complex internal experiences play out in the general medical setting and discusses how psychiatric consultants can help medical/surgical colleagues understand and manage difficult patient-physician relationships.

Listen to Dr. Muskin discuss "What to do when a patient makes you angry"

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Worried about high-dose prescribing? Manage risk for you and your patient


Neil S. Kaye, MD, DFAPA
Assistant clinical professor of psychiatry and human behavior, Assistant clinical professor of family medicine, Jefferson Medical College, Philadelphia, PA

Jacqueline M. Melonas, RN, MS, JD
Vice president, risk management, Professional Risk Management Services, Inc., Arlington, VA

Mr. B, age 35, is admitted for the fourth time to the inpatient service with hallucinations and delusions related to chronic schizophrenia. After appropriate attempts to control his symptoms, he has begun to respond to usual treatment with an atypical antipsychotic. He remains a “partial responder,” however, at the maximum FDA-approved dosage listed in the package insert (PI). What do you do next?

Because of this author’s (NSK) dual training in medicine and forensic psychiatry, other clinicians often ask me about patients such as Mr. B. Prescribing for patients who do not respond to standard dosages can create anxiety about going “off-label.” This article describes how to manage potential risk to yourself and your patient by communicating effectively and documenting informed consent.

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Informed consent: Is your patient competent to refuse treatment?


Debra A. Pinals, MD

Associate professor of psychiatry, Director of forensic education, Department of psychiatry, University of Massachusetts Medical School, Worcester, MA


Informed consent in clinical settings is designed to allow patients to make rational choices about their treatment before it begins. When a psychiatric patient declines a treatment you recommend, how can you balance the 2 ethical principles in medicine: beneficence toward the patient and respect for individual autonomy?

Some authors have raised concerns that informed consent in physician-patient interactions are at times an empty exercise undertaken solely to satisfy a legal expectation. If executed properly, however, informed consent can enhance the therapeutic alliance and help improve treatment adherence.

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Workplace mobbing: Are they really out to get your patient?


James Randolph Hillard, MD
Professor, Department of psychiatry, Associate provost for human health affairs, Michigan State University, East Lansing, MI


Initiated most often by a person in a position of power or influence, workplace mobbing has been described as “a desperate urge to crush and eliminate the target…. As the campaign proceeds, a steadily larger range of hostile ploys and communications comes to be seen as legitimate.” This behavior pattern has been recognized in Europe since the 1980s but is not well recognized in the United States.

This article discusses how to recognize symptoms of workplace mobbing, using a case study to illustrate the dynamics of this group behavior. An informed mental health professional can be of enormous help to a mobbing victim, but an uninformed professional can unwittingly make the situation much worse.

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Measurement-based psychiatric practice


Henry A. Nasrallah, MD
, Editor-in-Chief


Can you imagine an internist starting insulin for a patient with diabetes without obtaining a baseline glucose level? How would that internist know from visit to visit whether treatment was working and to what extent? How would he or she know how and when to adjust the dose to achieve hyperglycemia remission and a normal serum level?

If our medical colleagues wouldn’t dream of treating patients without measuring the symptoms of illness, why should psychiatric practice be different? Why aren’t psychiatrists measuring patients’ depression, anxiety, mania, or psychosis before and after starting psychopharmacologic agents?

I recently surveyed a sample of Current Psychiatry readers, asking about their use of standard measurement instruments in clinical practice. I conducted this online survey as part of the needs assessment for a CME workshop I am planning at the University of Cincinnati. As I expected, most of the respondents indicated that they do not utilize any of 4 clinical rating scales routinely used in the evidence-based controlled trials required for FDA approval of psychiatric medications.

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Tuesday, March 3, 2009

Fibromyalgia: Psychiatric drugs target CNS-linked symptoms


Sharon B. (Shay) Stanford, MD

Assistant professor of psychiatry and family medicine, Assistant director, Women’s Health Research Program, University of Cincinnati College of Medicine, Cincinnati, OH

Patients with fibromyalgia are a heterogeneous group, yet many describe a common experience: seeing multiple physicians who seem unable or unwilling to provide a diagnosis or treat their symptoms. This situation may be changing with the recent FDA approval of an anticonvulsant and 2 antidepressants for managing fibromyalgia symptoms.

These medications—pregabalin, duloxetine, and milnacipran—reflect a revised understanding of fibromyalgia as a CNS condition, rather than an inflammatory process in the muscles or connective tissue. As a result, psychiatrists—because of our experience with CNS phenomena and managing antidepressant and anticonvulsant medications—are likely to play a larger role in treating fibromyalgia.

Listen to Dr. Stanford discuss "Is fibromyalgia a somatoform disorder?"


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‘Night owls’: Reset the physiologic clock in delayed sleep phase disorder


R.
Robert Auger, MD

Assistant professor of psychiatry and medicine, Mayo Clinic College of Medicine Consultant, Mayo Center for Sleep Medicine, Rochester, MN

Delayed sleep phase disorder (DSPD)—characterized by a pathological “night owl” circadian preference—is seen most commonly in adolescents and is associated with psychiatric morbidity, psychosocial impairment, and poor academic performance. Proper identification of the condition can be enhanced with a variety of assessment tools, and successful treatment requires an awareness of potential endogenous and exogenous contributors.

This article describes what is known about DSPD and uses the case example to illustrate diagnostic assessment and treatment choices. Intriguing data support various pathophysiologic explanations for DSPD. Facilitating the adjustment of patients’ physiologic clocks is the overall goal in managing DSPD.

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Compulsive bruxism: How to protect your patients’ teeth


Bernard
Friedland, BChD, MSc, JD

Assistant professor of oral medicine, infection, and immunity, Harvard School of Dental Medicine, Boston, MA


Theo
C. Manschreck, MD, MPH

Professor of psychiatry, Harvard Medical School, Boston, MA

Oral habits such as bruxism—compulsive grinding or clenching of the teeth—can be a manifestation of obsessive-compulsive disorder (OCD) and other anxiety disorders. Bruxism also may be a side effect of selective serotonin reuptake inhibitors (SSRIs) used to treat OCD and depression. Other oral conditions can complicate treatment of these disorders.

Potentially serious sequelae of bruxism and similar behaviors include:

  • wearing down of teeth (more common)

  • necrosis of the pulpal tissues that results in non-vital teeth (less common).

The following case underlines the need for early referral to a dentist and close follow-up for patients who have tooth-related behaviors or are taking medications associated with a risk for such behaviors.

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Is Darwin still relevant? Advanced human brain breaks evolutionary rules


Henry A. Nasrallah, MD
, Editor-in-Chief


You may have noticed the buzz about Charles Darwin in the news: 2009 marks the 200th anniversary of his birth and the 150th anniversary of his monumental description of evolution in On the Origin of Species. Celebrations are scheduled around the world to honor the scientist who coined the phrase “natural selection” to explain the heritable process by which adaptive evolution occurs.

But is Darwin’s theory of evolution still relevant? The “game-changer” that is transforming evolution is the genetic mutation that led to dramatic growth in the primate cortex—especially the frontal lobe—culminating in the emergence of Homo sapiens. The overdeveloped brain that has helped our species adapt and survive may be transforming us into predators of all other species and a hazard to our planet.

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Monday, February 2, 2009

Controversies in bipolar disorder: Trust evidence or experience?


Gary
E. Miller, MD

Clinical professor of psychiatry, University of Texas Health Science Center, Houston, TX

Richard L. Noel, MD
Assistant clinical professor of psychiatry, University of Texas Health Science Center, Houston, TX


Today’s buzzword in health care is evidence-based medicine. Most clinicians would agree that evidence from clinical research should guide decisions about treating bipolar disorder. In theory, randomized controlled trials should tell us how to manage bipolar patients and achieve therapeutic success. But good theory does not always translate to good practice; many patients with bipolar disorder have poor outcomes, even when clinicians adhere to research-derived evidence.

The problem is that one well-designed study’s conclusions may contradict those of another equally well-designed study because of differences in subject selection, comorbidities, dosages, outcome criteria, and other variables. As a result, bipolar experts often disagree about issues as basic as antidepressants’ role in often disagree about issues as basic as antidepressants’ role in managing bipolar disorder and whether recurrent major depression should be considered a form of bipolar disorder. This leaves the clinician with the task of interpreting not only conflicting research findings but also conflicting expert opinion.

This article conveys clinical impressions gained from treating approximately 10,000 patients with bipolar disorder over 16 years. We do not claim to have resolved the issues in dispute, but we hope our experience will help practicing clinicians. We examine the evidence and address controversies in bipolar disorder—such as subthreshold hypomania, manic switches, use order—such as subthreshold hypomania, manic switches, use of antidepressants, juvenile depression/bipolar disorder, and atypical depression—together with our opinions on each.

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