Current Psychiatry

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Not all mood swings are bipolar disorder

2011-02-01T14:54:00.004-05:00

Robert A. Kowatch, MD, PhD, Professor of Psychiatry and Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH

Erin Monroe, CNS, Clinical Nurse Specialist, Division of Psychiatry, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH

Sergio V. Delgado, MD, Associate Professor of Psychiatry and Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH

Mood swings is a popular term that is nonspecific and not part of DSM-IV-TR diagnostic criteria for BD. The complaint of “mood swings” may reflect severe mood lability of pediatric patients with BD. This mood lability is best described by the Kiddie-Mania Rating Scale (K-MRS) developed by Axelson and colleagues as “rapid mood variation with several mood states within a brief period of time which appears internally driven without regard to the circumstance.” On K-MRS mood lability items, children with mania typically score:
Moderate—many mood changes throughout the day, can vary from elevated mood to anger to sadness within a few hours; changes in mood are clearly out of proportion to circumstances and cause impairment in functioning
Severe—rapid mood swings nearly all of the time, with mood intensity greatly out of proportion to circumstances
Extreme—constant, explosive variability in mood, several mood changes occurring within minutes, difficult to identify a particular mood, changes in mood radically out of proportion to circumstances.
Patients with BD typically exhibit what is best described as a “mood cycle”—a pronounced shift in mood and energy from 1 extreme to another. An example of this would be a child who wakes up with extreme silliness, high energy, and intrusive behavior that persists for several hours and then later in the day becomes sad, depressed, and suicidal with no precipitant for either mood cycle. BD patients also will exhibit other symptoms of mania during these mood cycling periods.

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Psychiatry behind bars: Practicing in jails and prisons

2011-02-01T14:49:00.006-05:00

Kathryn A. Burns, MD, MPH, Adjunct Clinical Assistant Professor of Psychiatry, Ohio State University, Columbus, OH, Assistant Clinical Professor of Psychiatry, Case Western Reserve University School of Medicine, Cleveland, OH

Over the last 2 decades mandatory prison sentences, longer prison terms, and more restrictive release policies have lead to a dramatic increase in the number of persons in jails and prisons. Currently, more than 2 million individuals are incarcerated in the United States. Psychiatric illness is over-represented in correctional populations compared with the general population—more than half of all inmates have a mental health diagnosis. Correctional facilities are legally obligated to address the medical and mental health needs of the persons committed to them. As a result, more psychiatrists are practicing in jails and prisons.

This article explains correctional facilities’ obligation to provide for inmates’ mental health needs and describes correctional mental health processes and how psychiatrists can play a role in screening, evaluation, and suicide prevention.

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Two vastly underutilized interventions can improve schizophrenia outcomes

2011-02-01T14:45:00.003-05:00

Henry A. Nasrallah, MD

Editor-in-Chief

Many psychiatrists would agree that schizophrenia is the most devastating psychiatric brain disease. Its disabling effects result in stigma, unemployment, poverty, loneliness, homelessness, victimization, incarceration, malnutrition, infections, social isolation, ostracism, discrimination, suicide, poor health, medical neglect, and early death

The consequences of schizophrenia are in many ways more malignant than those of cancer, where sympathy, prompt medical care, and preservation of friends and employment are assured. Also, unlike schizophrenia patients, persons with cancer are never hauled to jail, even when a slow-growing brain tumor causes erratic or violent behavior.

Bariatric procedures: Managing patients after surgery

2011-01-03T11:58:00.007-05:00

David B. Sarwer, PhD, Associate Professor of Psychology, Departments of Psychiatry and Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA

Lucy F. Faulconbridge, PhD, Assistant Professor of Psychology, Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA

Kristine J. Steffen, PharmD, PhD, Research Scientist, Neuropsychiatric Research Institute, Fargo, ND

James L. Roerig, PharmD, BCPP, Associate Professor, Department of Clinical, Neuroscience, University of North Dakota School of Medicine and Health Sciences, Fargo, ND

James E. Mitchell, MD, President and Scientific Director, Neuropsychiatric Research Institute, Christoferson Professor and Chair, Department of Clinical Neuroscience, University of North Dakota School of Medicine and Health Sciences, Fargo, ND

Bariatric surgery is the most effective treatment for obesity (defined as a body mass index [BMI] >30 kg/m²) and is recommended for extremely obese individuals (BMI >40 kg/m²) age >18. Most patients experience significant weight loss accompanied by improvements in mood, physical comorbidities, and quality of life. Despite these favorable outcomes, several aspects of postoperative care—such as management of mental health issues—remain unclear. Bariatric surgery candidates show high rates of preoperative psychopathology, particularly depression and dysphoria. Little is known about how bariatric surgery affects absorption of psychiatric medications, leaving prescribing clinicians with minimal guidance when a postoperative patient reports changes in mood symptoms.
This article discusses the psychosocial status of bariatric surgery candidates and presents a rationale for increased medication monitoring after surgery.
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Atypical antipsychotics for delirium: A reasonable alternative to haloperidol?

2011-01-03T11:50:00.007-05:00

David R. Spiegel, MD, Associate Professor of Clinical Psychiatry and Behavioral Sciences, Director of Consultation-Liaison Services, Department of Psychiatry and Behavioral Sciences, Eastern Virginia Medical School, Norfolk, VA

David Ahlers, MD, Psychiatry Resident, Department of Psychiatry and Behavioral Sciences, Eastern Virginia Medical School, Norfolk, VA

Grant Yoder, DO, Psychiatry Resident, Department of Psychiatry and Behavioral Sciences, Eastern Virginia Medical School, Norfolk, VA

Nabeel Qureshi, MD, Psychiatry Resident, Department of Psychiatry and Behavioral Sciences, Eastern Virginia Medical School, Norfolk, VA

Ms. B, age 48, is admitted to our hospital after overdosing on unknown amounts of amitriptyline, diphenhydramine, and laxatives. Three days after admission, the psychiatry service is consulted to assess her for “bipolar disorder.” Although Ms. B does not have a psychiatric history, her internist believes her pressured speech and psychomotor agitation warrant investigation.

During the initial psychiatric interview, Ms. B is disoriented, with fluctuating alertness and cognition. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is positive for delirium. We perform a delirium workup while we start Ms. B on olanzapine, 5 mg/d orally and 5 mg intramuscular (IM) every 8 hours as needed.

Ms. B’s laboratory results (complete blood count, complete metabolic profile, urinalysis, chest roentgenogram, vitamin B12 level, blood alcohol level, urine drug screen, arterial blood gas, and head CT) are unremarkable except for her amitriptyline/nortriptyline level, which is in the toxic range. On physical examination, Ms. B’s heart rate and temperature are elevated, her pupils are dilated and sluggish, and her skin is hot and dry. Based on these findings, we determine that Ms. B’s delirium most likely is an anticholinergic syndrome from amitriptyline/diphenhydramine toxicity. We discontinue olanzapine after only 2 doses because of its potential anticholinergic effects.

Shattering dogmas

2011-01-03T11:41:00.010-05:00

Henry A. Nasrallah, MD
Editor-in-Chief

Like all other medical specialties, psychiatry has its share of dogmas that are perpetuated via the clinical apprenticeship model from one generation of physicians to the next, despite the lack of hard evidence. They become “articles of faith” that go unchallenged by trainees who acquire them from their supervisors. A dogma masquerades as a truism and eventually becomes a sacred feature of the “clinical lore.”

Sooner or later, however, the bright light of scientific evidence will reveal the ersatz nature of a dogma and it will come crashing down. Similar to a revolution to depose a dictator, the demise of a dogma will have a salutary effect on medical practice and a liberating effect on practitioners.

Here are examples of psychiatric dogmas that were part of my training but have been/or are in the process of being taken to the slaughterhouse of obsolete tenets:

Psychiatrists should not touch their patients. Really! How can we be practicing physicians if we don’t? This dogma arbitrarily sexualized the physical exam, including drawing blood, measuring blood pressure or waist circumference, assessing neuroleptic-induced cogwheeling, or checking the body for a drug-induced rash. This dogma is the antithesis of good medical care for psychiatric patients, who frequently suffer from serious physical ailments and often do not have a primary care provider. It was created during the primordial phase of psychiatry (aka psychoanalysis) and is irrelevant in modern-era psychiatry.

Antiepileptics for psychiatric illness: Find the right match

2010-12-01T15:19:00.007-05:00

Theresa M. Gerst, PharmD, Clinical Assistant Professor, Division of Pharmacy Practice, College of Pharmacy, The University of Texas at Austin, Austin, TX

Tawny L. Smith, PharmD, BCPP, Clinical Pharmacy Specialist, Psychiatry, Seton Family of Hospitals, Austin, TX, Assistant Professor, Department of Psychiatry, University of Texas Southwestern Medical School, Dallas, TX

Nick C. Patel, PharmD, PhD, BCPP, Clinical Pharmacist, LifeSynch, Inc. Las Colinas, TX, Clinical Assistant Professor, Department of Psychiatry and Health Behavior, Medical College of Georgia, Augusta, GA

Although antiepileptic drugs (AEDs) are used to treat a spectrum of psychiatric disorders, in some instances they are prescribed without clear evidence of clinical benefit or safety. When considering prescribing an AED, ask yourself:

Does the evidence show the drug is efficacious for my patient’s disorder or symptoms?
Which adverse effects are associated with this medication?
What are the advantages of monitoring the patient’s serum drug concentration?

This review provides an evidence-based framework regarding the safe and effective use of AEDs in psychiatric patients.

How do SSRIs cause sexual dysfunction?

2010-12-01T14:47:00.007-05:00

Deepak Prabhakar, MD, MPH, Chief Resident, Outpatient Department, 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

Although selective serotonin reuptake inhibitors (SSRIs) are frequently prescribed and are better tolerated than older antidepressants, side effects such as sexual dysfunction limit patient acceptance of these medications. DSM-IV-TR categorizes medication-induced sexual dysfunction as a type of substance-induced sexual dysfunction. These dysfunctions are characterized by impairment of various sexual response phases.

Estimating the true incidence and prevalence of SSRI-related sexual dysfunction can be difficult. Zimmerman et al compared psychiatrists’ clinical assessments of depressed patients receiving ongoing treatment with results of a standardized side effects questionnaire and found that even though psychiatrists regularly inquired about sexual side effects, on the questionnaire patients reported higher rates of almost all sexual dysfunctions. The incidence of SSRI-induced sexual dysfunction also can be difficult to ascertain because some sexual dysfunctions frequently accompany a primary psychiatric disorder or physical illness. Balon suggested that the incidence of SSRI-associated sexual dysfunction is 30% to 50%, although others have reported higher incidences.

Recognizing the unheralded heroes of psychiatry

2010-12-01T14:22:00.037-05:00

Henry A. Nasrallah, MD
Editor-in-Chief

A large number of individuals contribute in many ways to the process of discovering, applying, and disseminating new psychiatric knowledge. I am, of course, referring to researchers, clinicians, teachers, and advocates who touch the lives of millions of persons who suffer from mental illness every year. This editorial is dedicated to singing the praises of those who quietly contribute to advancing psychiatry.

Patients. Tens of thousands of psychiatric patients sign an informed consent form and volunteer to participate in clinical trials to test new drugs in double-blind, placebo-controlled studies that could lead to FDA approval. Without these volunteers, it would be almost impossible to develop new medications.Research assistants. They are an army of skilled technical workers who do the heavy lifting in animal or human research and put in long hours to collect data or conduct tests. Yet they are rarely recognized for their critical contributions to science and clinical practice.

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Therapeutic neuromodulation

2010-11-03T09:37:00.002-04:00

Philip G. Janicak, MD, Professor, Department of Psychiatry, Rush University Medical Center, Chicago, IL

Sheila M. Dowd, PhD, Assistant Professor, Department of Psychiatry, Department of Behavioral Sciences, Rush University Medical Center, Chicago, IL

Jeffrey T. Rado, MD, Assistant Professor, Department of Psychiatry and Medicine, Rush University Medical Center, Chicago, IL

Mary Jane Welch, DNP, APRN, BC, CIP, Assistant Professor, College of Nursing, Director, Human Subjects Protection, Rush University Medical Center, Chicago, IL

The brain is an electrochemical organ, and its activity can be modulated for therapeutic purposes by electrical, pharmacologic, or combined approaches. In general, neuromodulation induces electrical current in peripheral or central nervous tissue, which is accomplished by various techniques, including:

electroconvulsive therapy (ECT)
vagus nerve stimulation (VNS)
transcranial magnetic stimulation (TMS)
deep brain stimulation (DBS).

It is thought that therapeutic benefit occurs by regulating functional disturbances in relevant distributed neural circuits. Depending on the stimulation method, the frequencies chosen may excite or inhibit different or the same areas of the brain in varying patterns. Unlike medication, neuromodulation impacts the brain episodically, which may mitigate adaptation to the therapy’s beneficial effects and avoid systemic adverse effects.

Neuromodulation techniques are categorized based on their risk level as invasive or noninvasive and seizurogenic or nonseizurogenic. Although these and other approaches are being considered for various neuropsychiatric disorders, the most common application is for severe, treatment-resistant depression. Therefore, this article focuses on FDA-approved neuromodulation treatments for depression, with limited discussion of other indications.

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Parricide: Characteristics of sons and daughters who kill their parents

2010-11-03T09:34:00.002-04:00

Sara G. West, MD, Assistant Professor of Psychiatry, Case Western Reserve University School of Medicine, Cleveland, OH

Mendel Feldsher, MD, Consulting Forensic Psychiatrist, Patton State Hospital, Patton, CA

Parricide—killing one’s parents—once was referred to as “the schizophrenic crime,” but is now recognized as being more complex. In the United States, parricides accounted for 2% of all homicides from 1976 to 1998, which is consistent with studies from France and the United Kingdom. Parricide’s scandalous nature has long attracted the public’s fascination.

This article primarily focuses on the interplay of the diagnostic and demographic factors seen in adults who kill their biological parents but briefly notes differences seen in juvenile perpetrators and those who kill their stepparents. Knowledge of these characteristics can help clinicians identify and more safely manage patients who may be at risk of harming their parents.

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Depression treatment for women with breast cancer

2010-11-03T09:31:00.003-04:00

Prachi Agarwala, MD, Psychiatry Resident, PGY-V, Department of Psychiatry, University of Michigan, Ann Arbor, MI

Michelle B. Riba, MD, MS, Clinical Professor, Department of Psychiatry, University of Michigan, Ann Arbor, MI

Psychological distress among patients with breast cancer is common and is linked to worse clinical outcomes. Depressive and anxiety symptoms affect up to 40% of breast cancer patients, and depression is associated with a higher relative risk of mortality in individuals with breast cancer. Psychotropic medications and psychotherapy used to treat depression in patients without carcinoma also are appropriate and effective for breast cancer patients. However, some patients present distinct challenges to standard treatment. For example, growing evidence suggests that some selective serotonin reuptake inhibitors (SSRIs) may reduce the effectiveness of tamoxifen, a chemotherapeutic agent. This article discusses challenges in diagnosing and treating depression in breast cancer patients and reviews evidence supporting appropriate psychiatric care.

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Are some nonpsychotic psychiatric disorders actually psychotic?

2010-11-03T09:24:00.008-04:00

Henry A. Nasrallah, MD
Editor-in-Chief

One of the basic psychiatric principles accepted by all practicing psychiatrists is that a delusion is a fundamental symptom of psychosis.

A delusion is defined as “a fixed false belief not commensurate with the person’s educational and cultural background” and is almost universally associated with schizophrenia and other psychotic disorders. But if we apply the notion that a fixed false belief is delusional, then several “nonpsychotic” psychiatric disorders would qualify as psychoses based on their core clinical symptoms, including major depressive disorder, obsessive-compulsive disorder, anxiety disorders, and others.

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CAM for your anxious patient: What the evidence says

2010-10-01T14:31:00.008-04:00

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
Ervin Davis, 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
Richard M. Bloch, PhD, Professor and director of research, 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
Sy Atezaz Saeed, MD, Professor and chair, Department of psychiatric medicine, Brody School of Medicine at East Carolina University, Greenville, NC

The number of people with psychiatric disorders who use complementary and alternative medicine (CAM) is on the rise. In surveys of patients seeking psychiatric care, estimates of CAM use range from 8% to 57%; the most frequent uses are for depression and anxiety disorders. A population-based study in the United States found that 9% of respondents had anxiety attacks and 57% of these individuals had used CAM. Similarly, in a Finnish population-based study (N=5,987) 35% of subjects reported some form of CAM use in the previous year; those with comorbid anxiety and depressive disorders used CAM most frequently.
Unfortunately, a MEDLINE search shows that the number of studies examining psychotropic medications dwarfs the number of studies on even the most common CAM treatments used for psychiatric disorders. Far more patients with diagnosed mental disorders are studied in trials of standard treatments than CAM treatments. Because very few studies evaluate the cost-effectiveness of CAM treatments for psychiatric disorders, the risk-to-benefit ratio is difficult to calculate. Although several CAM treatments for depressive disorders have enough support to be considered options, CAM options for anxiety disorders are fewer and have less evidence of efficacy.
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Hallucinations in children: Diagnostic and treatment strategies

2010-10-01T14:25:00.008-04:00

Kanwar Ajit S. Sidhu, MD, Assistant professor, Department of behavior medicine and psychiatry, West Virginia University, Charleston, WV

T.O. Dickey III, MD, Associate professor and program director, Department of behavior medicine and psychiatry, West Virginia University, Charleston, WV

Hallucinations in children are of grave concern to parents and clinicians, but aren’t necessarily a symptom of mental illness. In adults, hallucinations usually are linked to serious psychopathology; however, in children they are not uncommon and may be part of normal development.

A hallucination is a false auditory, visual, gustatory, tactile, or olfactory perception not associated with real external stimuli. It must be differentiated from similar phenomenon such as illusions (misperception of actual stimuli), elaborate fantasies, imaginary companions, and eidetic images (visual images stored in memory).

Re-envisioning psychosis: A new language for clinical practice

2010-10-01T14:18:00.009-04:00

Demian Rose, MD, PhD, Assistant professor, Department of psychiatry, University of California, San Francisco, San Francisco, CA

Barbara Stuart, PhD, Staff psychologist, Department of psychiatry, University of California, San Francisco, San Francisco, CA

Kate Hardy, ClinPsychD, Postdoctoral fellow, Department of psychiatry, University of California, San Francisco, San Francisco, CA

Rachel Loewy, PhD, Assistant professor, Department of psychiatry, University of California, San Francisco, San Francisco, CA

“I haven’t wanted to call it psychosis yet…”
“I’m not sure if this is psychosis or neurosis.”
“I wonder if there’s a psychotic process underneath all of this?”
“Psychotherapy won’t help psychosis.”

In our experience as practitioners in an early psychosis program, the above statements are common among mental health care providers. In our opinion, they are examples of vestiges of an archaic, overly simplistic clinical language that is not representative of current conceptions of psychosis as being on a continuum with normal experience.

The above quotes speak of psychosis as an all-or-none distinction: a “switch,” something fundamentally different from other psychological processes. In this article, we highlight common “all-or-none” myths about psychosis and argue for a more fluid, normalized psychosis language, where impairment is defined not by the absolute presence or absence of “weirdness” but instead by distress, conviction, preoccupation, and behavioral disturbance. We challenge the notion that the presence of psychosis mandates a “fast track” diagnosis that ignores the complexity of human experience.

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Questions about psychotherapy

2010-09-30T11:35:00.021-04:00

Henry A. Nasrallah, MD
Editor-in-Chief

As a National Institutes of Health-trained psychopharmacologist who also received substantial psychotherapy training during residency, I value both as pillars of psychiatric practice.

However, often I think about the evidence-based conduct of psychotherapy, which I regard as a neurobiologic treatment similar to drug therapy, and then I ask research questions that remain unanswered, such as:

What is the therapeutic “dose” of psychotherapy? Does it differ by type of therapy or the patient’s diagnosis?
Is the dose measured in the number of sessions or the time the patient is in a therapy session? Is there a loading dose? What is the maintenance dose?
What is the optimal schedule for psychotherapy? By what established criteria does a therapist determine how often to administer psychotherapy? Why weekly and not daily? Why not 2 or 3 times a day intensive psychotherapy for acutely ill patients? Is the scheduling based on the cost to the patient, the therapist’s availability, or insurance coverage rather than the patient’s needs?
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Schizophrenia in older adults

2010-09-01T12:00:00.001-04:00

Abhilash K. Desai, MD, FAPA, Associate professor, Director Center for Healthy Brain Aging, Department of neurology and psychiatry, Division of geriatric psychiatry, Associate professor, Department of internal medicine, Division of geriatric medicine, St. Louis University School of Medicine, St. Louis, MO

Mehrzad Seraji, MD, Fellow, Department of neurology and psychiatry, Division of geriatric psychiatry, St. Louis University School of Medicine, St. Louis, MO

Maurice Redden, MD, Instructor, Department of neurology and psychiatry, Division of geriatric psychiatry, St. Louis University School of Medicine, St. Louis, MO

Ramasubba Tatini, MD, Private practice, St. Louis, MO

The number of older adults (age ≥65) who developed schizophrenia before age 45 is expected to double in the next 2 decades; the 1-year prevalence of schizophrenia among older adults is approximately 0.6%. This article reviews how positive, negative, and cognitive symptoms and social functioning change over decades and discusses strategies for reducing the impact of long-term antipsychotic use on neurologic and physical health. Although some patients experience schizophrenia onset later in life, in this article we focus on older adults who developed the illness before age 45.

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Vaccine for cocaine addiction

2010-09-01T11:52:00.010-04:00

Robert M. Anthenelli, MD, Current Psychiatry Section Editor for substance use disorders, is professor of psychiatry, psychology, and neuroscience, director of addiction sciences division and Tri-State Tobacco and Alcohol Research Center, University of Cincinnati College of Medicine, and director of Substance Dependence Program, Cincinnati Veterans Affairs Medical Center, Cincinnati, OH.

Eugene Somoza, MD, PhD, Professor of clinical psychiatry, University of Cincinnati College of Medicine, and director of the Cincinnati Addiction Research Center, Cincinnati, OH.

Unlike opioid or alcohol abuse, for cocaine dependence there are no FDA-approved pharmacotherapies, which leaves psychosocial treatment as the standard of care for the estimated 1.6 million individuals in the United States who abuse cocaine. However, researchers are developing a novel way to help cocaine-dependent patients reduce their drug use. Therapy for addiction–cocaine addiction (TA-CD) is thought to curb cocaine use by engaging the body’s immune reaction and stopping cocaine molecules from reaching the brain, thereby reducing the drug’s pleasurable effects.

One researcher working on this vaccine, Eugene Somoza, MD, PhD—the principal investigator of the Ohio Valley Node of the National Institute on Drug Abuse clinical trials network of 16 universities and treatment programs—discusses with CurrentPsychiatry Section Editor Robert M. Anthenelli, MD, how TA-CD works and how it might be used in clinical practice.

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Integrating psychiatry with other medical specialties

2010-09-01T11:49:00.005-04:00

Henry A. Nasrallah, MD
Editor-in-Chief

As a specialty that deals with brain disorders, psychiatry is now much more integrated with other medical and surgical specialties than in the past. Psychiatry is no longer perceived as a ‘different’ discipline and has successfully embraced the medical model without abandoning its biopsychosocial principles.

But some chasms remain and several separations persist, impacting not only the image of the specialty but also psychiatrists and their mentally ill patients. Some issues need to be addressed before full integration can occur.

Bipolar disorder and substance abuse

2010-08-02T14:55:00.003-04:00

Bryan K. Tolliver, MD, PhD, Assistant professor, Clinical neuroscience division, Department of psychiatry and behavioral sciences, Medical University of South Carolina, Charleston, SC

The high prevalence of substance use disorders (SUDs) in persons with bipolar disorder (BD) is well documented. Up to 60% of bipolar patients develop an SUD at some point in their lives. Alcohol use disorders are particularly common among BD patients, with a lifetime prevalence of roughly 50%. Recent epidemiologic data indicate that 38% of persons with bipolar I disorder and 19% of those with bipolar II disorder meet criteria for alcohol dependence. Comorbid SUDs in patients with BD are associated with:

poor treatment compliance
longer and more frequent mood episodes
more mixed episodes
more hospitalizations
more frequent suicide attempts.

The impact of co-occurring SUDs on suicidality is particularly high among those with bipolar I disorder. Frequently referred to as “dual diagnosis” conditions, co-occurring BD and SUDs may be more accurately envisioned as multi-morbid, rather than comorbid, illnesses.

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Adolescents who self-harm

2010-08-02T14:53:00.002-04:00

John Peterson, M, Director, child and adolescent psychiatry, Denver Health Medical Center, Associate professor, Department of psychiatry, University of Colorado School of Medicine, Denver, CO

Stacey Freedenthal, PhD, Associate professor, Graduate School of Social Work, University of Denver, Denver, CO

Adam Coles, MD, Resident Department of psychiatry, University of Colorado School of Medicine, Denver, CO

Josh, age 16, gets poor grades in school and occasionally smokes marijuana and abuses inhalants. After his girlfriend breaks up with him, he cuts his wrist with a hunting knife. While bleeding profusely, Josh calls his mother at work, who calls 911. The cut is deep and requires sutures. Josh says he did not try to kill himself; he only wanted to carve his girlfriend’s initials into his wrist to show his love for her.

When treating teenagers with self-harming thoughts and behavior, it may be difficult to distinguish suicide attempts from self-injury without intent to die. Understanding adolescent self-harm, suicide risk assessment, and treatment options guides clinicians to appropriate interventions. Recognizing the need for aggressive treatment—including psychiatric hospitalization—is essential to keeping self-harming teenagers safe.

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Depression in older adults

2010-08-02T14:49:00.003-04:00

Nabil Kotbi, MD, Assistant professor of psychiatry, Weill Medical College of Cornell University, New York-Presbyterian Hospital, White Plains, NY

Nahla Mahgoub, MD, Instructor in psychiatry, Weill Medical College of Cornell University, New York-Presbyterian Hospital, White Plains, NY

Anna Odom, PhD, Instructor of psychology in psychiatry, Weill Medical College of Cornell University, New York-Presbyterian Hospital, White Plains, NY

Depression in older adults (age ≥65) can devastate their quality of life and increase the likelihood of institutionalization because of behavioral problems. Depression is a primary risk factor for suicide, and suicide rates are highest among those age ≥65, especially among white males. The burden of geriatric depression can extend to caregivers. Prompt recognition and treatment of depression could help minimize morbidity and reduce suffering in older adults and their caregivers.

Although geriatric depression varies in severity and presentation, common categories include:

major depressive disorder (MDD)
vascular depression
dysthymia
depression in the context of dementias, psychosis, bipolar disorder, and executive dysfunction.

Diagnoses in this population generally correspond with DSM-IV-TR criteria, but geriatric depression has distinct clinical manifestations.

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Treat the patient, not the disease

2010-08-02T14:46:00.005-04:00

Henry A. Nasrallah, MD
Editor-in-Chief

Personalized care is at the heart of good medical care. It is an indispensable ingredient for optimal clinical outcomes because each patient is unique, as an individual and as a patient, and requires customized treatment.

If 10 patients with depression walk into a psychiatrist’s office on any given day, each will be different and should be treated accordingly. Their symptoms may be similar thematically but they differ widely in presentation and content. Their medical and psychiatric histories and social, educational, religious, ethnic, socioeconomic, and attitudinal diversity can be stunning in complexity and disparity. Just as patients’ symptoms can be similar yet different, so can their response to a specific antidepressant or psychotherapy. Their clinical and functional outcomes will vary widely in degree and valence. Every psychiatrist expects (and enjoys) the richness of patient backgrounds and manages each individually.

Given these individual differences among our psychiatric patients, why are practitioners being barraged by various entities to abandon the traditional medical approach to their patients? Why is there a push to transform personalized clinical care to an assembly-line system, where patients are defined by their disease and are managed like “human widgets” as though they can be “processed” in an identical, protocolized, mechanical manner? This is completely antithetical to the magnificent personal approach inherent in the classic and highly effective doctor-patient relationship.

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Treating insomnia in women

2010-07-06T11:23:00.005-04:00

Vithyalakshmi Selvaraj, MD, PGY-4 resident, Department of psychiatry, Creighton University, Omaha, NE

Sriram Ramaswamy, MD, Assistant professor, Department of psychiatry, Creighton University, Omaha, NE

Daniel R. Wilson, MD, PhD, Professor and chair of psychiatry, Department of psychiatry, Creighton University, Omaha, NE

Compared with men, women have a 1.3- to 1.8-fold greater risk for developing insomnia. Multiple factors contribute to this increased risk of insomnia, including:

hormonal changes across the reproductive cycle
predilection to mood and anxiety disorders
psychosocial factors, such as being single, separated, or widowed.

Furthermore, the higher prevalence of psychiatric disorders during the reproductive stages may confer additional risk for sleep problems.

Insomnia has tremendous impact on health and quality of life, resulting in reduced work productivity and increased absenteeism, accidents, and health care costs. This article examines the factors that contribute to women’s sleep difficulties throughout the life cycle, and suggests evaluation and treatment approaches appropriate for each phase.

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Cholesterol, mood, and vascular health

2010-07-06T11:20:00.003-04:00

Jess G. Fiedorowicz, MD, MS, Assistant professor, Departments of psychiatry and epidemiology, Roy A. and Lucille J. Carver College of Medicine, College of Public Health, University of Iowa, Iowa City, IA

William G. Haynes, MD, Professor, Department of internal medicine, Institute for Clinical and Translational Science, Roy A. and Lucille J. Carver College of Medicine, University of Iowa, Iowa City, IA

Does low cholesterol predispose to depression and suicide, or vice versa? A growing body of literature examining the putative links among cholesterol, mood disorders, and suicide has produced inconsistent findings and unclear clinical implications that may leave psychiatrists unsure of how to interpret the data. Understanding cholesterol’s role in mood disorders may be relevant to the 2 primary causes of excess deaths in patients with mood disorders: suicide and vascular disease health.

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Psychiatric futurology

2010-07-06T11:18:00.002-04:00

Henry A. Nasrallah, MD
Editor-in-Chief

Few things capture the imagination like the future. I recall how after reading Alvin Toffler’s seminal book Future Shock in college, I was fascinated by how the future could change us as people and as a culture.

During medical school and psychiatric residency, the breathless pace of scientific discoveries—especially in neuroscience—prompted me to dream about the potentially stunning medical breakthroughs of the future. My frustrations about severe, disabling psychiatric brain disorders were tempered by hope that tomorrow will unfold new knowledge that will unravel the dark mysteries of psychotic delusions, obsessive-compulsive disorder (OCD) rituals, intractable narcissism, suicidal urges, and homicidal impulses. The future, I frequently mused, will provide all answers for definitive diagnoses, effective treatments, prevention, and cures for all psychiatric disorders.

Hope for restoring wellness for our suffering patients continues to sustain me and my fellow psychiatrists. The ongoing gush of neuroscience advances that elucidate the divine details of brain and mind continue to inspire us. However, we are getting impatient with the slow translation of groundbreaking basic science discoveries into new and dramatic clinical applications for our long-suffering patients. A collective mantra is building up: We want our future and we want it now!

Evolving advances are lurking in our future, some of which already are palpable and we hope may soon become clinical realities liberties.

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Lowering Alzheimer's risk

2010-06-07T09:10:00.003-04:00

Nazem Bassil, MD, Fellow, Division of geriatric psychiatry, St. Louis University School of Medicine, St. Louis, MO

George T. Grossberg, MD, Samuel W. Fordyce Professor, Department of neurology and psychiatry, St. Louis University School of Medicine, St. Louis, MO

Pharmacologic treatments for Alzheimer’s disease (AD) may improve symptoms but have not been shown to prevent AD onset. Primary prevention therefore remains the goal. Although preventing AD by managing risk factors such as age or genetics is beyond our control, we can do something about other factors.

This article summarizes the findings of many studies that address AD prevention and includes an online-only bibliography for readers seeking an in-depth review. The evidence does not support a firm recommendation for any specific form of primary prevention and has revealed hazards associated with estrogen therapy and nonsteroidal anti-inflammatory drugs. Most important, it suggests that you could reduce your patients’ risk of developing AD by routinely supporting their mental, physical, and social health.

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Impaired physicians

2010-06-07T09:06:00.004-04:00

Robert P. Bright, MD, Instructor of psychiatry, Department of psychiatry and psychology, Mayo Clinic, Scottsdale, AZ

Lois Krahn, MD, Professor of psychiatry, Department of psychiatry and psychology, Mayo Clinic, Scottsdale, AZ

As physicians, recognizing impairment in our colleagues or ourselves can be difficult. The American Medical Association defines an impaired physician as one who is unable to fulfill personal or professional responsibilities because of psychiatric illness, alcoholism, or drug dependence. Impairment is present when a physician is unable to perform in a manner that conforms to acceptable standards of practice, exhibits serious flaws in judgment, and provides incompetent care.

Recognizing when a physician is impaired, deciding whether to report him or her to the state medical board, and referring a colleague for treatment can be challenging. This article will:

review substance abuse, cognitive decline, and other causes of impairment
address legal and ethical issues involved in reporting a colleague to the state medical board
provide resources for physician treatment and assistance.

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A psychiatrist/lawyer crossfire

2010-06-07T09:01:00.009-04:00

Henry A. Nasrallah, MD
Editor-in-Chief

Do lawyers understand psychiatry? To answer that semi-rhetorical question, I imagined the following conversation between 2 friends, Barry the barrister and Harry the psychiatrist.

Barry: Harry, I think psychiatry is a politically incorrect discipline.

Harry: How so, my dear friend?

Barry: Well, psychiatrists hospitalize people against their will, strip them of their civil liberties, and force them to take powerful, mind-altering drugs.

Harry: Barry, when you think about it objectively, involuntary hospitalization is a compassionate and legal act for people suffering from a brain disease that makes them suicidal or homicidal and a danger to themselves and others with no insight that they are sick. Once treated and improved, patients regain their civil liberties and often thank us for providing care against their will. And a person needs a healthy brain to properly exercise one’s civil liberties.

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Antidepressants in bipolar disorder

2010-05-06T16:03:00.002-04:00

Joseph F. Goldberg, MD Associate clinical professor, Department of psychiatry, Mount Sinai School of Medicine, New York, NY, Affective Disorders Research Program, Silver Hill Hospital, New Canaan, CT

Few topics are as controversial as the role of antidepressants for patients with bipolar disorder. Although depression usually is the predominant, most enduring mood state in bipolar disorder, clinicians often face uncertainty about using antidepressants because of concerns about safety and efficacy. Whether and when to use antidepressants for bipolar depression hinges on complex parameters that preclude any single, simple rule.

Rather than asking if antidepressants are useful or detrimental for depressed patients with bipolar disorder, a more practical question might be: Under what circumstances are antidepressants likely to be beneficial, deleterious, or ineffective for an individual patient? Because “real world” patients often have idiosyncrasies that defy practice guidelines’ generic treatment recommendations, clinicians who practice in the proverbial trenches need strategies to tailor treatments to each patient that are informed—but not dictated—by evidence-based research.

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Women's response to antidepressants

2010-05-06T15:59:00.004-04:00

Wendy K. Marsh, MD, Assistant professor, Department of psychiatry, University of Massachusetts Medical School, Worcester, MA

Kristina M. Deligiannidis, MD, Assistant professor of psychiatry, Director, Depression Specialty Clinic, Center for Psychopharmacologic Research and Treatment, University of Massachusetts Medical School, Worcester, MA

Both men and women respond well to antidepressants, yet there are notable differences between the 2. Understanding why men and women may differ in response to antidepressants helps clinicians better tailor their treatment choice and dosing.

This article outlines some of differences—and lack thereof—in response rates to antidepressants. Our discussion of why these differences may occur is framed in the context of pharmacokinetics, pharmacodynamics, and the influence of gonadal hormones on antidepressant-related neurotransmitter systems. The second section focuses on major reproductive phases of adult women (the menstrual cycle, pregnancy, postpartum, and menopause) and how antidepressant response rates can influence clinical decision making, such as antidepressant timing, dose, and choice of potential adjunct treatments.

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Combination therapy is here to stay

2010-05-06T15:55:00.003-04:00

Henry A. Nasrallah, MD
Editor-in-Chief

Although psychiatrists commonly combine psychotropic medications, researchers malign the practice as “not evidence-based.” Research is finally catching up with clinical practice, however, and evidence is rapidly accumulating that for many patients with severe psychiatric disorders, 2 drugs are better than 1.

This should not be surprising because “real world” patients with schizophrenia, bipolar disorder, major depression, anxiety disorders, or obsessive-compulsive disorder (OCD) often do not achieve remission and are hobbled—even disabled—by their illness without combination therapy. The same principle holds true for general medical illnesses such as hypertension, cancer, or diabetes, where combination therapy is the norm rather than the exception.

Recent studies have confirmed better efficacy with combination therapy compared with monotherapy for several psychiatric illnesses.

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2010 Psychopharmacology Update

2010-04-27T11:33:00.004-04:00

A one-day psychopharmacology symposium

Save the date!

Saturday, October 23, 2010, 7:45 am – 5:00 pm
Kingsgate Marriott Conference Hotel*
Cincinnati, Ohio

Join us for this interactive, live symposium where nationally renowned faculty will address:

Treatment Resistant Depression: A Multi-Functional Pharmacologic Approach
The Philosophy, Process, and Application of Evidence-Based Psychopharmacology

Symposium Director
Henry Nasrallah, MD
Professor of Psychiatry and Neuroscience
University of Cincinnati College of Medicine

Faculty
Stephen M. Stahl, MD, PhD
Adjunct Professor of Psychiatry
University of California, San Diego

Leslie Citrome, MD, MPH
Professor of Psychiatry
New York University School of Medicine

*A discounted room rate will be available for participants of the Psychopharmacology Update.

Email Updates
To receive email updates about this conference directly to your inbox, please contact: kathy.wenzler@qhc.com

To receive a copy of the invitation to this conference please send your full name and address to: kathy.wenzler@qhc.com

Adjunctive anticonvulsants in alcohol withdrawal

2010-04-02T08:52:00.002-04:00

David R. Spiegel, MD, Associate professor, Department of psychiatry and behavioral sciences, Director of consultation-liaison services, Eastern Virginia Medical School, Norfolk, VA

Daiana Radac, MD, Resident, Eastern Virginia Medical School, Norfolk, VA

Benzodiazepines are the mainstay of alcohol detoxification treatment, with extensive evidence supporting their efficacy and relative safety. The risk of benzodiazepine-alcohol interaction, however, and psychomotor and cognitive impairments associated with benzodiazepine use may limit early rehabilitation efforts in hospitalized patients. Cross-tolerance with alcohol also limits benzodiazepines’ potential benefit in outpatients with substance use disorders.

Adding anticonvulsants to acute benzodiazepine therapy has been shown to decrease alcohol withdrawal symptom severity, reduce seizure risk, and support recovery, particularly in patients with multiple alcohol withdrawal episodes. After detoxification, long-term anticonvulsant use may reduce relapse risk by decreasing post-cessation craving, without abuse liability.

Although not all studies endorse adding anticonvulsants to benzodiazepines for managing alcohol withdrawal syndrome (AWS), we present 3 cases in which anticonvulsants were used successfully as adjuncts to lorazepam. Valproic acid, levetiracetam, and gabapentin offer advantages in acute and long-term therapy of alcohol dependence with efficacy in AWS, low abuse potential, benign safety profile, and mood-stabilizing properties.

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PTSD and mood disorders

2010-04-02T08:44:00.003-04:00

Steven C. Dilsaver, MD, Comprehensive Doctors Medical Group, Inc., Arcadia, CA

Major depressive disorder (MDD) and bipolar spectrum disorders are associated with some symptoms of—and fully defined—posttraumatic stress disorder (PTSD). Many traumatic experiences can lead to this comorbidity, the most common being exposure to or witnessing combat for men and rape and sexual molestation for women.Trauma has major prognostic and treatment implications for affectively ill patients, including those whose symptoms do not meet PTSD’s full diagnostic criteria.

This article aims to help clinicians by:

presenting evidence characterizing the overlap between affective disorders and PTSD
reviewing evidence that the bipolar spectrum may be broader than generally thought, an insight that affects PTSD treatment
making a case for routine PTSD screening for all patients with affective illnesses
recommending PTSD treatments tailored to the patient’s comorbid affective disorder

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A psychiatric manifesto

2010-04-02T08:42:00.002-04:00

Henry A. Nasrallah, MD
Editor-in-Chief

Psychiatry is one of the most rapidly evolving medical disciplines. Its scientific foundation is neuroscience, which is growing at the most explosive pace in science. Yet the public and even other medical specialists still envision psychiatrists sitting behind a couch scribbling Freudian jargon on a yellow pad. For that reason, I propose that we create a manifesto that promulgates the basic tenets of psychiatry and make it a permanent, living document on CurrentPsychiatry.com.

So I present my initial iteration of a psychiatric manifesto here. I invite all readers and CurrentPsychiatry.com visitors to suggest valid additions and/or modifications. I will serve as the custodian and editor of the manifesto, in charge of its continuous update as a living document

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Antidepressant discontinuation syndrome

2010-03-12T09:47:00.004-05:00

David J. Muzina, MD, Vice president and national practice leader for neurosciences, Medco Health Solutions, Fort Worth, TX

Most psychiatrists have encountered patients who report distressing symptoms when they have forgotten to take their antidepressant for a few days or during changes in the medication regimen. A discontinuation syndrome can occur with almost any antidepressant, highlighting the need to slowly taper these medications when discontinuation is part of a treatment plan.

This article discusses antidepressant discontinuation syndrome (ADS) in a patient who experienced substantial distress after a rapid antidepressant taper in preparation for electroconvulsive therapy (ECT). My goal is to raise awareness of ADS, promote early detection of the syndrome, and address proper prevention and management strategies.

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Children with tic disorders

2010-03-12T09:39:00.005-05:00

Elana Harris, MD, PhD, Assistant professor, Division of child and adolescent psychiatry, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH

Steve W. Wu, MD, Assistant professor, Division of child neurology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH

Tics, such as strong eye blinks or repetitive shoulder shrugs, can distress a child or his/her parents, but the conditions associated with tic disorders often are more problematic than the tic disorder itself. High rates of comorbid conditions are recognized in persons with Tourette syndrome, including:

obsessive-compulsive disorder (OCD) in >80%
attention-deficit/hyperactivity disorder (ADHD) in ≤70%
anxiety disorders in 30%
rage, aggression, learning disabilities, and autism less commonly.

The strategy we recommend for managing tic disorders includes assessing tic severity, educating the family about the illness, determining whether a comorbid condition is present, and managing these conditions appropriately. Above all, we emphasize a risk-benefit analysis guided by the Hippocratic principle of “do no harm.”

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Connecting the dots: Psychiatrists are virtuosos

2010-03-12T09:33:00.003-05:00

Henry A. Nasrallah, MD
Editor-in-Chief

“Connecting the dots” has emerged as a buzzword in our media and popular culture. This expression is a picturesque way to denote competence and implies an uncanny ability to recognize and integrate what appear to be multiple unrelated data points into an important, actionable pattern. An incisive decision or intervention often follows.

When I hear this expression, I contemplate the centrality of connecting the dots in psychiatric practice. In fact, it is a ubiquitous and indispensable approach to diagnosing and treating our patients. Psychiatrists are trained to be highly skilled at connecting not only one set of dots, but often a bewildering array of complex and disparate sets of dots related to each patient we evaluate and manage. It is impossible to arrive at an accurate psychiatric diagnosis and construct an appropriate and comprehensive treatment plan without connecting countless overt and covert dots related to interconnected pathologies across a patient’s brain, mind, and body. As part of the assessment, psychiatrists often presage the existence of dots that are not yet on their clinical radar and inquire about them with the patient and multiple corroborative sources. That’s what a good psychiatric interview and history taking usually entails.

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Is seasonal affective disorder a bipolar variant?

2010-02-03T11:11:00.002-05:00

Kathryn A. Roecklein, PhD, Assistant professor of psychology, The University of Pittsburgh, Pittsburgh, PA

Kelly J. Rohan, PhD, Associate professor of psychology, University of Vermont, Burlington, VT

Teodor T. Postolache, MD, Associate professor of psychiatry, Director, Mood and Anxiety Program, University of Maryland School of Medicine, Baltimore, MD

Seasonal affective disorder (SAD) is an umbrella term for mood disorders that follow a seasonal pattern of recurrence. Bipolar I disorder (BD I) or bipolar II disorder (BD II) with seasonal pattern (BD SP) is the DSM-IV-TR diagnosis for persons with depressive episodes in the fall or winter and mania (BD I) or hypomania (BD II) in spring or summer.

This article compares BD SP with major depressive disorder with seasonal pattern (MDD SP), in which depressive episodes usually occur in fall or winter and fully remit in spring or summer. Rather than being categorically distinct from each other, BD SP and MDD SP may represent extreme variants on a seasonal depression continuum from unipolar to bipolar.

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Older patients and substance abuse

2010-02-03T11:09:00.002-05:00

Shannon M. Drew, MD, Assistant clinical professor of psychiatry, Yale School of Medicine, New Haven, CT

Kirsten M. Wilkins, MD, Assistant professor of psychiatry, University of Oklahoma College of Medicine-Tulsa, Tulsa, OK

Louis A. Trevisan, MD, Assistant clinical professor of psychiatry, Yale School of Medicine, New Haven, CT

As the eldest post-World War II “baby boomers” turn 64 this year, relaxed social attitudes about substance use during their lifetimes may predict an increasing risk for substance use disorders (SUDs) in older Americans. This article describes screening and treatment approaches shown to be most effective for identifying and managing primary SUDs in older patients. Our goal is to help you ask the right questions and provide appropriate care.

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Psychosis in women

2010-02-03T11:06:00.002-05:00

Mary V. Seeman, MD, Professor emerita, Department of psychiatry, University of Toronto

Psychoses of unknown cause usually begin in late adolescence or early adulthood. Less frequently the onset occurs in later adulthood (age ≥40). Late-onset psychosis is much more prevalent in women than in men for reasons that are imperfectly understood.

When you are evaluating a midlife woman with first onset of psychosis, don’t assume an illness of unknown cause (bipolar disorder or schizophrenia) until after you have done a comprehensive search for triggers of her psychotic symptoms. After age 40, women are more likely than men to develop psychosis because of gender-specific medical and psychological precipitants.

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Treatment resistance is our greatest challenge

2010-02-03T11:02:00.003-05:00

Henry A. Nasrallah, MD
Editor-in-Chief

We all have patients with thick charts, the mentally ill individuals who push our clinical skills to the limit. They respond poorly to the entire algorithm of approved medications for depression, anxiety, or psychosis. Their symptoms hardly budge despite multiple psychotherapeutic interventions. They lead lives of quiet desperation and suffer through many hospitalizations and outpatient visits. They are perennially at high risk for harm to self or others. They get many side effects yet meager benefits from pharmacotherapy. Their social and vocational functions often are minimal to nil. Their life has little meaning beyond doleful patienthood.

Treatment resistance in my long-suffering patients incites me to ask important questions that beg for answer.

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When to admit an adolescent to a psychiatric inpatient facility

2010-01-05T11:59:00.003-05:00

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

Admitting an adolescent to a psychiatric inpatient facility may be necessary to address a crisis. Interdependent links among the patient, family, and support network complicate the determination of whether an adolescent requires inpatient care. To make the best decision, a psychiatrist needs to understand the youth’s difficulties within family, school, and community.

The decision to admit an adolescent rests on:

the clinician’s ability to evaluate the risk of harm and functional status
how much support the family and/or caregivers can provide
the clinician’s knowledge of treatment resources available to the adolescent and family.

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Borderline, bipolar, or both?

2010-01-05T11:52:00.004-05:00

Jess G. Fiedorowicz, MD, Assistant professor, Department of psychiatry, University of Iowa, Carver College of Medicine, Iowa City, IA

Donald W. Black, MD, Professor, Department of psychiatry, University of Iowa, Carver College of Medicine, Iowa City, IA

Borderline personality disorder (BPD) and bipolar disorder are frequently confused with each other, in part because of their considerable symptomatic overlap. This redundancy occurs despite the different ways these disorders are conceptualized: BPD as a personality disorder and bipolar disorder as a brain disease among Axis I clinical disorders.

BPD and bipolar disorder—especially bipolar II—often co-occur and are frequently misidentified, as shown by clinical and epidemiologic studies. Misdiagnosis creates problems for clinicians and patients. When diagnosed with BPD, patients with bipolar disorder may be deprived of potentially effective pharmacologic treatments. Conversely, the stigma that BPD carries—particularly in the mental health community—may lead clinicians to:

not even disclose the BPD diagnosis to patients
lean in the direction of diagnosing BPD as bipolar disorder, potentially resulting in treatments that have little relevance or failure to refer for more appropriate psychosocial treatments.

To help you avoid confusion and the pitfalls of misdiagnosis, this article clarifies the distinctions between bipolar disorder and BPD. We discuss symptom overlap, highlight key differences between the constructs, outline diagnostic differences, and provide useful suggestions to discern the differential diagnosis.

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Listen to Dr. Fiedorowicz explains why a thorough and rigorous psychiatric history is essential to distinguish BPD from bipolar disorder

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New Year’s resolutions to help our patients

2010-01-05T11:43:00.008-05:00

Henry A. Nasrallah, MD
Editor-in-Chief

Most New Year’s resolutions have a self-oriented, narcissistic flavor: “I will ___ (lose weight to look better; exercise to become healthier; stop smoking to live longer; travel to an exotic location; make more money than last year so I can buy that sports car I’ve always wanted; etc.).”

As psychiatrists, we are particularly attuned to the human condition around us, so perhaps we can transcend our personal desires and resolve to do something to help seriously mentally ill patients. Our stressful lives as toiling psychiatrists pale when compared with the lifelong anguish, stigma, disability, loneliness, and poverty faced by many of our chronically ill patients. Beyond providing them with good evidence-based care, I can think of several meaningful resolutions to improve mentally ill persons’ quality of life.

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

2009-12-02T10:33:00.004-05:00

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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Listen to Dr. Citrome discuss discusses how to determine if clozapine is an appropriate choice for your patient

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

2009-12-02T10:29:00.002-05:00

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

2009-12-02T10:25:00.003-05:00

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?

2009-12-02T10:19:00.004-05:00

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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Testifying for civil commitment

2009-11-04T09:16:00.007-05:00

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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Listen to Dr. Mossman explain how to prepare to testify in civil commitment proceedings

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New algorithm for pediatric bipolar mania

2009-11-03T16:10:00.007-05:00

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?

2009-11-03T16:04:00.015-05:00

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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Pharmacologic treatment of sex offenders

2009-10-02T11:06:00.003-04:00

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.

CAM for patients with depression

2009-10-01T11:35:00.007-04:00

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.

Listen to Dr. Manuel discuss how to negotiate CAM use with patients