In “Major Depression After Recent Loss Is Major Depression-Until Proved Otherwise” (Psychiatric Times, December 2008, page 12), Dr Pies highlights one of the more provocative questions encountered when we train in clinical psychiatry: “Suppose your new patient Mr Jones, tells you he is feeling ‘really down.’ He meets all DSM–IV symptomatic and duration criteria for a major depressive episode (MDE) after having lost his wife to cancer 2 weeks ago. Should you diagnose MDD?”
Several classes of hypnotic medication are available: the older barbiturates and their derivatives; benzodiazepines; chemically distinct “z-compounds”; antihistamines and antihistaminic antidepressants; and melatoninergic compounds. The use of hypnotic medications continues at a high rate. However, some switching to the shorter-acting benzodiazepines has occurred. The z-compounds-eszopiclone, zolpidem, and zaleplon-have become popular; they seem to have fewer residual effects than the benzodiazepines. Even so, care is needed in prescribing such hypnotics for the elderly.
In Comfortably Numb, author Charles Barber reports that in 2002, 16% of the inhabitants of Winterset- a quintessentially American town in Iowa-had an antidepressant prescribed for them and asks, “Why did Winterset want to get numb?” With this question, Barber begins a journey through the world of psychiatry and psychopharmacology that spans most of the book.
Lecturing around the country has left us with the powerful impression that both psychiatrists and primary care physicians are hungry for new ways to think about and treat depression and the myriad symptoms and syndromes with which it is associated-including attention deficit disorder, insomnia, chronic pain conditions, substance abuse, and various states of disabling anxiety. Primary care physicians also seem especially excited to learn that depression is not just a psychiatric illness but a behavioral manifestation of underlying pathophysiological processes that promote most of the other conditions they struggle to treat-including cardiovascular disease, diabetes, cancer, and dementia.1,2
Psychotropic treatment can often prevent the relapse of psychotic and mood symptoms. However, many patients take medication intermittently or not at all; or the symptoms may be only partially responsive to medication. Therefore, there is a need for interventions that can supplement the effect of medication and improve treatment outcomes.
The assessment and treatment of psychiatric symptoms in persons with cognitive dysfunction are becoming increasingly important. Prevalence estimates of dementia in the United States range from 5% in those aged 71 to 79 years to 25% to 50% in those 90 or older.
Autism spectrum disorders (ASDs) are a group of 5 neuro developmental conditions (autism, Asperger syndrome, pervasive developmental disorder not otherwise specified [PDD-NOS], Rett syndrome, and disintegrative childhood disorder).1 Once thought to be rare, the incidence of these disorders is now estimated to be 1 in 150 children in the general population.2 Furthermore, the number of recognized cases has increased markedly in recent years.
I almost destroyed the backseat pocket of an airline seat this summer. The vandalism was inadvertent, assuredly, though the anger that fueled it was not. While waiting for my plane to take off, I had read a magazine article claiming to show that fMRI (functional magnetic resonance imaging) studies were “uncovering” the voting preferences of test subjects. An adjacent article announced that researchers could now predict the buying preferences of other test subjects using the same imaging technologies.
Clinicians who treat patients with strong antisocial traits commonly struggle with the tension between conceptualizing them as either man or beast.2 On one hand, there is the well-intended goal of helping the offender develop into a more functional “human being.” On the other, there are the common emotional reactions of anger, disgust, and even fear of predation.3
Allegations of suppressed research, promotion of drugs for unapproved uses, payment of kickbacks to physicians, and ghostwriting of a major journal article surfaced recently when the Department of Justice unsealed a civil complaint against Forest Laboratories and Forest Pharmaceuticals, Inc.
This article emphasizes core philosophies and components of effective dual disorder programs.
Over the past century, the syndrome currently referred to as ADHD has been conceptualized in relation to varying cognitive problems including attention, reward response, executive functioning, and other cognitive processes.
Brief psychotherapy is not the name of a specific model or theory of treatment. Rather, it describes an approach that attempts to make psychotherapy as efficient and practically helpful as possible within a limited time frame. The aim of brief therapy is to speed up the process of change, amplify patient involvement, and foster more focused psychotherapy sessions. Over the years, several approaches to brief psychotherapy have evolved. Some advocate a handful of sessions; others involve more than 20 sessions (eg, psychodynamic therapy).
Traumatic experiences are common in childhood and adolescence and can have significant psychological effects on the child’s emotional well-being and overall development. Outcomes can be affected positively or negatively depending on responses and interventions.
In my January column (“Fishing Expeditions and Autism: A Big Catch for Genetic Research?” Psychiatric Times, January 2009, page 12), I described the great difficulties researchers face characterizing the genetic basis of the disease. Complexities range from trying to establish a stable diagnostic profile to making sense of the few isolated mutations that show clear associations (either with disease or syndrome variants).
Book Review: What one thing could we do to improve our relationships, our work, and the way we learn? According to Dr Medina, we should make friends with our brains and learn to work with them, not against them. In Brain Rules, Medina outlines 12 practical ideas to help acquaint us with the ways our brains function and the ways we can engage positively as individuals and as a society.
The rationale for the use of anticonvulsants in anxiety disorders is supported by neurobiological underpinnings that make these compounds a likely alternative for short-term treatment.
My first job after residency involved working at a large Veterans Affairs hospital in an outpatient dual diagnosis treatment program that focused on the comorbidity of schizophrenia and cocaine dependence. Having recently completed a chief resident position at the same hospital’s inpatient unit that focused on schizophrenia without substance abuse, I was struck by how “unschizophrenic” my new patients were. They were organized and social. Their psychotic symptoms were usually limited to claims of “hearing voices,” for which insight was intact and pharmacotherapy was readily requested.
The number of persons in the United States who take prescription opioids for pain is growing. Sullivan and colleagues2 found that from 2000 to 2005 there was a 19% increase in the number of patients who received prescriptions for opioids to manage chronic noncancer pain conditions. Based on a survey conducted from 1998 to 2006 with more than 19,000 subjects, Parsells Kelly and associates3 reported that 2% of the US population 18 years and older legally used opioids as analgesics at least 5 days per week for 4 or more weeks-and that another 2.9% used these drugs less frequently.
The words attributed to Socrates resonate with the perspectives of many contemporary parents and clinicians.1 The endurance of the concern suggests something fundamental about the psychopathology of deviant, disruptive behavior of youth. Yet clinicians struggle to understand its origins, to help parents control their children, and to help the children control themselves. Clinically, this manifests in failed pharmacological treatments, incompleted courses of individual therapy, problems in engaging families in treatment, and controversies over which therapy is most effective.
Women with bulimia nervosa (BN) respond more impulsively during psychological testing than do women without eating disorders, according to a recent article in Archives of General Psychiatry.1 Functional MRI showed differences in brain areas responsible for regulating behavior in women with and without BN.
The FDA is forcing manufacturers of all antiepileptic drugs to include new warnings of possible suicide ideation in the prescribing information and also to prepare a new Medication Guide to be distributed by pharmacies to consumers. In addition, the companies will have to produce a Risk Evaluation and Mitigation Strategy for each drug, which the FDA only requires for drugs with possible adverse effects it considers especially dangerous.
Fibromyalgia syndrome is a chronic condition that consists of a pervasive set of unexplained physical symptoms with widespread pain (involving at least 3 of 4 body quadrants and axials) of at least 3 months duration and point tenderness at 9 bilateral locations (Figure) as the cardinal features.1 Patients with FM report a set of symptoms, functional limitations, and psychological dysfunctions, including persistent fatigue (78.2%), sleep disturbance (75.6%), feelings of stiffness (76.2%), headaches (54.3%), depression and anxiety (44.9%), and irritable bowel disorders (35.7%).1 Patients also report cognitive impairment and general malaise, “fibro fog.” This pattern of symptoms has been reported under various names (such as tension myalgia, psychogenic rheumatism, and fibromyositis) since the early 19th century.
The 2 most common anxiety disorders are generalized anxiety disorder (GAD) and panic disorder. Approximately 5.7% of people in community samples will meet diagnostic criteria for GAD in their lifetime; the rate is about 4.7% for panic disorder (with or without agoraphobia).1 GAD-which is characterized by excessive and uncontrollable worry about a variety of topics (along with associated features such as trouble sleeping and impaired concentration)-is often chronic and is associated with significant costs to the individual and to society.
Suicide risk assessment is a core competency that all psychiatrists must have.1 A competent suicide assessment identifies modifiable and treatable protective factors that inform patient treatment and safety management.2 Psychiatrists, unlike other medical specialists, do not often experience patient deaths, except by suicide. Patient suicide is an occupational hazard. A clinical axiom holds that there are 2 kinds of psychiatrists: those who have had patients commit suicide-and those who will.
