Nothing better reflects the difficulties of finding silver bullets for depression treatment than the results of the nearly completed Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study, the largest clinical trial of its kind. With results imminent from the last of 4 trials in the study, psychiatrists are hoping for considerably more clinical guidance than what the first 3 levels of the trials produced.
Working in the emergency care setting takes choice out of the equation when dealing with cross-cultural issues for both clinicians and patients. As clinicians, we need not have had any prior scientific interest in a patient's particular culture, and the patient has not cautiously selected us to trust. We are thrown together.
Addictive disorders are among the leading causes of disability worldwide; however, misuse of and addiction to alcohol and illicit substances is often not appreciated as relevant to the care of older adults.
Borderline personality disorder (BPD) is a serious illness involving multiple symptoms and mal adaptive behaviors. According to DSM-IV, “the essential feature of borderline personality disorder is a pervasive pattern of instability of interpersonal relationships, self-image, and affects” (p. 650). This pervasive pattern of instability also applies to behaviors that are impulsive and potentially damaging, including excessive spending, sexual promiscuity, reckless driving, binge eating, and substance misuse.
Coping with the issue of drug-drug interactions (DDIs) is one of the most challenging aspects of modern psychopharmacology. Psychiatrists are treating patients with medication regimens of ever-increasing complexity.
Older adults have higher rates of suicide than younger adults in many industrialized nations.
By now, many clinical researchers and practitioners recognize the strong association between cognitive impairment and type 2 diabetes, which, in its early stages, is characterized by hyperinsulinemia and insulin resistance. Although this relationship has not been observed uniformly, more than 20 large-scale epidemiologic studies have reported a link between type 2 diabetes and in creased risk of cognitive impairment and dementia, including Alzheimer disease (AD), the most common type of dementia.
The emotional and functional consequences of sensory impairment in older persons have not been well studied despite the increasing prevalence of vision loss, in particular, and its substantial adverse effects. This review examines the impact of vision loss on psychological health, discusses factors that may reduce its negative effects, and describes new in terventions to help older people cope with eye diseases such as age-related macular degeneration (AMD).
Alzheimer dementia (AD) represents a profound global health concern. By the year 2050, the prevalence of AD in the United States is expected to reach 15 million. At present, there are 4.5 million cases in the United States, which equals an estimated cost of $100 billion each year in medical and family expenses.
Initial studies-such as the stepped collaborative care intervention, Texas Medication Algorithm Project (TMAP), and German Algorithm Project (GAP) phase 2-predominantly investigated whether following an expert opinion–based clinical algorithm (irrespective of the content of the algorithm) led to a better outcome than treatment as usual did
Many physicians, including psychiatrists, may shy away from seeing elderly patients with symptoms of dementia because they imagine that there are a large number of alternative diagnoses and that differential diagnosis is complicated. In fact, however, the number of possible diagnoses in most situations is relatively small and the diagnosis of dementia in older patients is certainly feasible in primary care psychiatry.
Office management of attention-deficit/hyperactivity disorder (ADHD) differs in many important ways from ADHD management conducted in a research environment. In clinical trials, treatments and eligible patients are selected in advance by committees, patients are randomized to different management strategies, and both clinicians and pa tients are blinded to the treatments.
In this essay, however, I wish to use another source of data about callings my personal experience of a calling to medicine and, later, to psychiatry.
Just how “hot” is the topic of conflict of interest in psychiatry? The answer was brought home to me dramatically this past May at the APA meeting in Toronto. During the meeting, I had the opportunity to chair a symposium titled “Pharmaceutical Industry Influence in Psychiatry.” My copresenters and I showed up well ahead of time to meet and prepare introductions. As we gazed out at the empty seats, we joked that there would be at least 5 people in attendance since, after all, there were 5 presenters.
For patients with psychiatric illnesses, the treatment team today often consists of a psychotherapist, psychiatrist, and/or primary care physician-all of whom are motivated to achieve the same goals. These include full remission of symptoms; improvement and restoration of function, quality of life, and relationships; and the delay and preferably prevention of recurrence of symptoms.
The setting of a fast-paced emergency department (ED) or psychiatric emergency service makes it especially difficult to sensitively elicit and address an individual patient's needs and concerns. When considering the myriad differences in culture that come into play between a patient and a psychiatrist or other mental health care clinician, optimal diagnosis and treatment can be even more challenging, as the cases described here illustrate. The important influence of culture cannot be stressed enough. Taking the time to understand "where the patient is coming from" can prevent an already stressful, highly emotionally charged situation from becoming even more convoluted.
The 2 most common types of mass casualty events are natural disasters (eg, hurricanes) and mass interpersonal violence (eg, terrorist attacks).1 The psychological effects of such traumas vary in type and extent. More severe responses occur in the context of greater event severity; closer proximity to the epicenter of the event; physical injury; witnessing injury or death of others (especially family or loved ones); higher levels of peritraumatic terror, panic, horror, or helplessness; major property loss; and circumstances in which the survivor is unable to access social support and post-disaster resources.2,3 Certain survivor-related variables also can be contributory, including a history of previous trauma exposures, previous or current psychiatric disorder, female gender (probably based on the greater number of prior traumas already experienced by women by the time they encounter the event), older age, and lower socioeconomic status.1,2
All clinicians know that culture influences virtually every aspect of a person's life. Sometimes the influence of culture is obvious; other times it is subtle. In either case, culture as a clinical variable is often overlooked. Being cognizant of the influence of culture is especially important for clinicians who manage psychiatric emergencies, because failing to do so can lead to misdiagnosis and delays in treatment.
Anxiety disorders are the most prevalent psychiatric disorders in the United States. Although effective treatments are available, such as the SSRIs and cognitive-behavioral therapy (CBT), it is estimated that in about 40% of patients, anxiety disorders are partially or completely resistant to first-line treatment.
Anyone who is close to someone who abuses alcohol or drugs knows all too well that substance abusers do not typically seek treatment until they have experienced years of substance-related problems. During the first year after onset of a diagnosable substance use disorder, only 1 of 5 alcohol-dependent persons and 1 of 4 drug-dependent persons receive treatment.
Although studies now suggest that some psychotropic medication regimens have a somewhat higher success rate than the one-third rule would have predicted, psychiatrists are still left with the problem of why it is that only one third to one half of patients who are treated get better, and why fewer still sustain that improvement over time
The treatment of unipolar major depression presents a substantial challenge for the clinician. Major depression is a common disorder with a high propensity for relapse and recurrence.
The problem of treatment resistance in bipolar disorder begins with its definition. Characterizing the phases of bipolar disorder as manic, mixed, hypomanic, or depressed does not do justice to the reality for many persons with this disorder.
In 1931, Gananath Sen and Kartick Chandra Bose reported on the use of an alkaloid extract from the Rauwolfia serpentina plant in the treatment of hypertension and "insanity with violent maniacal symptoms." They noted that dosages "of 20 to 30 grains of the powder twice daily produce not only a hypnotic effect but also a reduction of blood pressure and violent symptoms
Parkinson gait is characterized by shuffling, including a decreased stride length and gait speed. The diminished stride and gait speed coupled with increased cadence puts the patient at risk for postural instability resulting in falls.
The prognosis for patients with intracerebral hemorrhage (ICH) is poor. The 30-day mortality rate is 25% to 50%, and half of these deaths occur within the first 48 hours.
Delirium is characterized by an altered level of consciousness, decreased attention span, acute onset, and fluctuating course. About 15% of elderly patients admitted to the hospital have delirium as a presenting or associated symptom. Delirium will develop in another 15% of elderly patients during hospitalization.
HHD, which affects only a small percentage (4%) of patients with PD, is characterized by adverse psychomotor effects related to dopamine replacement therapy.
ChEIs Beneficially Affect REM Sleep in AD. Cholinesterase inhibitors (ChEIs) do not modify disturbances of sleep-wake rhythm or sleep continuity in patients with either Alzheimer disease (AD) or frontotemporal dementia (FTD), but they may have a beneficial effect on REM sleep, according to investigators from the University of Marburg in Germany.
A team from the The Scripps Research Institute (TSRI) was able to reactivate a gene, the metabolic silencing of which is responsible for Friedreich ataxia, a rare autosomal recessive neurodegenerative disorder that leaves affected persons crippled and vulnerable to scoliosis, diabetes, and heart disease. The research team, led by Joel Gottesfeld, PhD, a professor in the Department of Molecular Biology at TSRI in La Jolla, California, set about identifying and testing compounds that inhibited histone deacetylases in lymphocytes from persons with Friedreich ataxia. They hit upon one-BML-210-that reactivated the frataxin gene.
