Antiepileptics for psychiatric illness: Find the right match

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.

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How do SSRIs cause sexual dysfunction?

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.

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Recognizing the unheralded heroes of psychiatry

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

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

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

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?

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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