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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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

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

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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).

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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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