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 fiancé 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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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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