Physicians are often conflicted regarding prescription medications for pain, especially pain complicated by insomnia and anxiety. Concerns that patients may become addicted to medications, exacerbated by limited time available to get to know patients, can lead to underprescribing of needed medications, patient suffering, and needless surgery. At the other extreme, pressure to alleviate patients' distress can lead to overprescribing, needless side effects, and even addiction.
Few phenomena in medicine aremore confounding than the diagnosesinvolving deception:malingering, Munchausen syndrome,Munchausen by proxy (MBP), and factitiousdisorder.
A recent 16-week, randomized, double-blind, placebo-controlled trial found that treating children and adolescents with metformin (Glucophage, Fortamet) may help curb the weight gain and decrease the insulin sensitivity and abnormal glucose metabolism that often results from atypical antipsychotic use.
In the past few years, a great deal of information has been learned about how the brain processes ambiguous information. Data exist that allow us to view what the brain looks like when we are deliberately trying to deceive someone. In response, a number of corporations have been established that use these data--and the imaging technologies that gave them to us--to create brain-based lie detectors.
This article focuses on 4 issues in psychiatric malpractice: prescribing, liability for suicide, informed consent, and duty to protect under the Tarasoff v Regents of the University of California ruling. Malpractice is a civil wrong actionable by law. There are 2 goals of malpractice suits: the first is to make an injured plaintiff whole by an award of money, and the second is to inform the profession how courts will decide similar cases in the future.
Recent discoveries in neuroscience have ramifications for all aspects of clinical and forensic practice, including diagnosis, treatment, and testimony in civil and criminal justice cases.
Unlike a pure psychiatric disabilityevaluation, mental and emotionaldamage claims require anassessment of causation. Today, treatingpsychiatrists are increasingly asked toprovide this assessment, since mentaland emotional damages are widelyclaimed in the United States as a remedyin legal actions.
Paraphilias are defined by DSM-IV-TR as sexual disorders characterized by "recurrent, intense sexually arousing fantasies, sexual urges or behaviors generally involving (1) nonhuman objects, (2) the suffering or humiliation of oneself or one's partner, or (3) children or other nonconsenting persons that occur over a period of 6 months" (Criterion A), which "cause clinically significant distress or impairment in social, occupational, or other important areas of functioning" (Criterion B). DSM-IV-TR describes 8 specific disorders of this type (exhibitionism, fetishism, frotteurism, pedophilia, sexual masochism, sexual sadism, voyeurism, and transvestic fetishism) along with a ninth residual category, paraphilia not otherwise specified (NOS).
Each year, the CDC's National Center for Health Statistics creates a report on the current health status of the US. In addition to the issues usually addressed in this report, such as information on morbidity and mortality, vaccination rates, and use of health care resources, the recently released report contained a special feature on pain.
The assessment of malingering presents a significant challenge for mental health clinicians.
A forensic book with a superb format, clinical wisdom, and eminent readability.
Binge eating disorder is more common than anorexia and bulimia combined, according to a national survey, but many physicians are unaware of the problem. The guidance and evidence discussed here highlight the key issues in recognizing and managing the disorder.
Attention-deficit/hyperactivity disorder (ADHD) is often underappreciated and inadequately treated in adults. Long thought to be a disorder of childhood, ADHD is now believed to persist into adulthood in approximately half of all cases.
Positron emission tomography (PET) of the brain using an enhanced chemical marker has the ability to differentiate among normal aging, mild cognitive impairment, and Alzheimer disease (AD). Researchers writing in the New England Journal of Medicine said the technique is "potentially useful as a noninvasive method to determine regional cerebral patterns of plaques and tangles associated with Alzheimer's disease."
At the core of alcoholism is the pathologically increased motivation to consume alcohol at the expense of natural rewards with disregard for adverse consequences. naltrexone and acamprosate represent the first generation of modern pharmacotherapies that target this pathology.
Senate committee passage of a landmark bill (S. 558) expanding mental health coverage requirements for employers may have hit its first roadblock.
Recent issues of Psychiatric Timeshad articles focusing on psychiatricpractice guidelines and algorithms. Dr Michael Fauman examinedthe extent to which they are used,how they are used, and studies that havevalidated their usefulness comparedwith usual care.
In his column "Concerns About [Clinical] Practice Guidelines" or CPGs (Psychiatric Times, December 2006, page 28), Dr Michael A. Fauman addressed questions from his readers about a previous column, including the question, "How can physicians be sure that CPGs are free of bias from managed care and insurance companies?" He noted that CPGs are created through a process of expert consensus, and went on to say, "It is reasonable to question how these experts were selected and why they should be considered more qualified to draw conclusions from the research data."
Several months ago, a new psychiatrist came from a prestigious university in the Northeast to work in the VA hospital out West where I practice. During one of our initial conversations, he expressed the emphatic view that "benzodiazepines are only useful for acute alcohol withdrawal or psychiatric emergencies and other than that they have no place in pharmacology." I juxtaposed this position with that of several of our older clinicians, who are equally strong advocates of the generous use of benzodiazepines for a variety of psychiatric symptoms.
Surveys of ECT use in the United Statesshow disparate applications, with theprincipal use in academic medical centers.While more than half the treatmentsare given to outpatients, wholepopulations are underserved.
The increase in diagnostic and therapeutic options has made the selection of the best medical strategy more complex. Physicians are often forced to work and make decisions under time pressure, which complicates matters.
Treatment with second-generation antipsychotic medications produced only modest improvement in the psychosocial functioning of patients with schizophrenia, a follow-up report from investigators of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) concluded.
I recently read issues of 2 research journals that collectively must hold some kind of scientific publishing record. The first journal, Pharmacogenomics, printed 14 papers back-to-back, all devoted to a single, large-scale study: discovering the genetics of chronic fatigue syndrome (CFS). By contrast, the journal Nature was more typical, printing single articles that described mostly research from single studies, and 1 that listed more than 100 authors. These authors are part of the Allen Brain Project, which consists of dozens of scientists who are mapping gene expression profiles of the mouse brain. By the time I finished reading about these monumental efforts, my head ached.
Successful intervention for Alzheimer disease requires an early and timely diagnosis. Caregivers of persons with AD often state that an average of 2 years passes from the onset of symptoms to a formal diagnosis.
Compared with schizophrenia, adherence behavior has been relatively overlooked in depression and other mood disorders. Major depression is increasingly thought of as a chronic illness. In most chronic illnesses, ideal concordance is the exception, not the rule.
Driven by a wave of neuroscientific advances, no area in the field of psychiatry has grown more explosively in the past few decades than psychopharmacological practice.
My teachers or supervisors never mentioned God 50 years ago when I was a resident. Psychoanalytic theory dominated the teaching program; in retrospect, the silence about God, religious beliefs and activities, and spirituality in general almost certainly reflected in part an unspoken allegiance to Freud and his negativity about religion.
Although treatment-resistant depression is defined in terms of a person's depression being resistant to medication, it usually also means that the patient has been unresponsive to whatever psychotherapy has been tried along the way. What might not be clear from the above but is known by all clinicians is that patients with TRD experience much internal suffering and misery.
Over the past 50 years, psychiatry has increasingly become psychiatric medicine coincident with the enormous developments in our understanding of and ability to effectively use clinical psychopharmacology to treat patients with psychiatric illnesses. There have been both increased understanding of the molecular mechanisms underlying the effects of psychiatric medications and increased numbers of psychiatric medications. The latter has occurred in tandem with a similar explosion in the availability of medications to treat a host of other medical conditions. In fact, the repertoire of available medications expands virtually every few weeks.
Challenges related to the mechanisms of care, trust, and personal belief systems keep ethnic patients with Parkinson disease (PD) from participation in clinical trials, according to a study by researchers affiliated with National Institutes of Neurological Disorders and Stroke (NINDS) from the Medical University of South Carolina in Charleston. These researchers highlighted findings from 2 futility trials conducted by researchers from NINDS revealing that of 413 patients recruited, 91% were white persons and only 3% each were African American, Asian, and Hispanic persons.
