Most psychiatrists and other physicians routinely prescribe medication for off-label use. This article focuses on how to minimize patient harm from off-label therapies and how to protect oneself from legal problems that may arise from off-label prescribing.
Epilepsy affects about 2% of the US population and is a disability fraught with unique psychosocial and health care challenges. Authors of a study appearing in the journal Epilepsy and Behavior note that the ongoing quest of persons with epilepsy is to find informed physicians, effective therapies, and resources to help them achieve an adequate level of normalcy.
Huntington disease (HD) is a devastating hereditary, degenerative brain disorder for which there is, at present, no effective treatment or cure. More than a quarter of a million Americans have HD or are at risk for the disease because of potential genetic transmission. The disease slowly diminishes the affected person's ability to walk, think, talk, and reason. As it progresses, concentration and short-term memory diminish and involuntary movements of the head, trunk, and limbs increase.
A right-handed woman aged 19 years is referred for intractable clinical events. The patient's medical history is remarkable for anxiety, depression, and attention-deficit/hyperactivity disorder; migraine headache; and Lyme disease for which she received 6 months of intravenous antibiotic therapy.
It can be difficult to determine whether unusual, paroxysmal behavior represents a seizure or a nonepileptic event. Patients with convulsive, clonic movements may, in fact, be experiencing psychogenic events.
That depression, anxiety, sleep disorders, and other neuropsychological conditions are often associated with chronic pain isn't news to most neurologists. But physicians who do not specialize in pain management are largely unaware of a growing body of research suggesting that the race (a genetic classification) or ethnicity (a cultural classification) of a patient with chronic pain may determine the patient's risk of neuropsychological symptoms.
Prevalence of depression in PD is estimated to range from 7% to 76%. The variation is largely attributed to the diversity of the populations under study, differences in the definition of depression, and the fact that some studies used point prevalence and other studies used monthly prevalence. Also, the prevalence of depression varies with fluctuations of cognitive status and other comorbidities that are an integral part of PD.
Effective antiepileptic therapy depends on balancing seizure control and tolerability, said Manoj Raghavan, MD, PhD, during a presentation at the midyear meeting of the American Epileptic Society in Chicago this past June. Tolerability places a ceiling on how far you can go in controlling seizures using medications alone, he commented.
The results of a recent study are changing the way physicians prescribe antiseizure medications to pregnant patients with epilepsy.
How do you know whether a patient with end-stage dementia is experiencing pain or suffering when the patient has lost the ability to communicate verbally? Experts say a clinician should have a high index of suspicion that a patient with end-stage dementia is experiencing pain or suffering.
From the contentious debate over federal funding for stem cell research, it would be easy to assume that if restrictions were lifted, research would blossom and miraculous therapies would spring up like mushrooms after a downpour. Those who have been following the controversy over federal subsidies know that even if funds were unrestricted, investigators would still have to clear several significant hurdles before treatments derived from human embryonic stem cells (hESCs) could become a reality.
epilepsy, migraine, headache, Parkinson disease, parkinsonism
Telepsychiatry often involves the working together of clinicians, patients, and organizations that are both geographically and culturally distinct. Thus, culturally appropriate care is an important component of telepsychiatry.
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
