Addiction & Substance Use

SAN FRANCISCO -- Given the high prevalence of substance abuse in patients with attention deficit hyperactivity disorder (ADHD), psychiatrists need to consider comorbidity in assessment of both conditions.

Suicide is a serious public health problem that ranks as the 11th leading cause of death in the United States. Within the 15- to 24-year-old age group, it is the third leading cause of death.1 Many suicide victims have had contact with the mental health system before they died, and almost one fifth had been psychiatrically hospitalized in the year before completing suicide. A recent review found that psychiatric illness is a major contributing factor to suicide, and more than 90% of suicide victims have a DSM-IV diagnosis.

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.

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.

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).

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.

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.

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.

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.

When friends and family need medical advice, they often consult me even though I'm nothing more than a medical news writer. Folks think it is worthwhile to tell me rather than a real medical professional about the curious pain that occasionally shoots through their leg or their heart or their head. They ask my advice about what new intervention they might try for a chronic condition or whether they really need to get that prescribed vaccine or take those antimicrobials before going off to Madagascar or some such place.

Just 2 minutes before an episode of the television show Boston Legal aired, Roger Pitman, MD, professor of psychiatry at Harvard Medical School, received a telephone call from his sister-in-law informing him that the show would include a segment on propranolol, a drug he was researching for the prevention and treatment of PTSD.

What is comorbidity? Psychiatric comorbidity refers to the occurrence of 2 or more mental or substance use disorders within a certain period. Research shows that comorbidity of substance use and other psychiatric disorders is common and often worsens the prognosis for each disorder.

The FDA finds itself straddling a data divide as it decides how to rewrite the black box warnings on the labels of SSRI antidepressants. The agency will almost certainly mandate that the existing black box warning, which addresses suicidality in children and adolescents, be expanded to include young adults up to age 25 or 30. But in what might be a pioneering move for the FDA, the agency will probably also include new verbiage in the warning related to the benefits of antidepressants to people over the age of 30 years.

This month, I decided that the time had finally come the time to throw out the 4 boxes I had stored in my attic since leaving my childhood home. These boxes lay piled in a corner with 30 years of dust and dirt on their lids. Unopened in all these years, they were filled with things I didn't need or miss. But before tossing them out, I decided to take a look inside.

The price and availability of psychiatric drugs is expected to be one of the major issues as Congress decides whether to try to find a way to force pharmaceutical manufacturers to lower the prices they charge Medicare Part D drug plans. Antidepressants, antipsychotics, and anticonvulsants are among the 6 categories for which Part D formularies must make available "all or substantially all" medications. As a result, the formularies are unable to bring to bear the drug price reduction strategies they use in other categories.

When I was young and attended church services with the family, the sermons of a certain priest, who was a historian, consisted of anecdotes about desperation and compassion that occurred in such places as Nazi concentration camps, Hell's Kitchen or the Bowery in Depression-era New York, or Dickens-like orphanages somewhere. At the end of his anecdote, the priest would dolefully lilt, Examine your own conscience. It was the point during the sermon when a person might startle awake after nodding off.

Amyotrophic lateral sclerosis (ALS) is a progressive, debilitating, fatal disease that involves degeneration of upper and lower motor neurons. Patients often initially present with limb or bulbar weakness, atrophy, and spasticity, followed by progressive loss of ambulation and, ultimately, respiratory failure, which is the most common cause of death.

Despite the enormous progress made in stroke diagnosis and treatment in recent years, patients continue to experience stroke-related deficits that clinicians-even those working on stroke rehabilitation units-do not always recognize or record. In a recent study of 53 patients who underwent screening tests within 10 days of admission to a stroke unit, every impaired patient had at least 1 undocumented cognitive or sensory deficit. The authors suggested that without formal testing with standardized assessments, much stroke-related impairment goes unrecognized and perhaps untreated.

Given the lack of a good evidence base for pharmacological treatment of neuropsychiatric symptoms of dementia, are there any effective treatments for such problems as agitation, aggression, delusions, hallucinations, repetitive vocalizations, and wandering? A recent review suggests that nondrug interventions that address behavioral issues and unmet needs may be helpful, as may caregiving interventions and the use of bright light therapy.

Recent imaging studies have shown that patients with autism spectrum disorders (ASDs) who were presented with images of human faces had lower responses in amygdala activity than controls. These studies strengthen the connection between the amygdala and the abnormal social-emotional behavior seen in patients with ASDs, said Chris Ashwin, PhD, senior research associate at the Autism Research Centre in the Department of Psychiatry at the University of Cambridge, UK.

Despite the increased use of methylphenidate in preschoolers with attention deficit/hyperactivity disorder (ADHD), few data are available regarding the efficacy and safety of methylphenidate in this population. Methylphenidate has been approved by the FDA for the treatment of ADHD in children aged 6 years or older. A recent large-scale, controlled trial of methylphenidate for the treatment of preschoolers with ADHD provides clinically relevant and greatly needed information for clinicians who treat these children.

Cocaine dependence is a devastating disorder that is associated with a host of medical and psychosocial risks. This complex disorder is made up of distinct clinical components that are interwoven into a cycle of addiction (Figure 1). Cocaine activates ancient pleasure centers that dominate our thoughts, behaviors, and priorities, producing a pleasure-reinforced compulsion to use the drug. Repeated use dysregulates brain pleasure centers and paves the way to addiction through craving and impaired hedonic function.1 Euphoria and craving drive the cycle of addiction through positive and negative reinforcement, respectively, and they provide targets for pharmacological interventions.

Anxiety is a ubiquitous, natural affective state that is essential for evolutionary survival. Nearly as common, however, are experiences of anxiety that exceed social, psychological, or physiological needs, leading to functional impairment. Indeed, primary anxiety disorders, including panic disorder, social phobia, and generalized anxiety disorder (GAD), represent the most common category of mental illness in the United States. Secondary, or reactive, anxiety is also widespread and can arise not only from numerous medical causes but also from the psychological process of coping with illness.

In a meeting this past December, an FDA advisory committee recommended that the black-box warning of antidepressant-linked suicidality in children and adolescents should also warn of the risk in young adults. Meanwhile, the NIMH had announced in November its sponsorship of 5 new studies to elucidate this adverse drug effect, particularly focusing on the SSRI antidepressants.

Delirium is a disorder that lies at the interface of psychiatry and medicine. It is an acute organic syndrome caused by an underlying medical condition and is defined clinically by disturbances in cognitive function, attention, and level of consciousness.1 Delirium is considered a syndrome because of the constellation of signs and symptoms associated with the disorder, coupled with a wide variety of potential etiologies.

The following case histories illustrate some of the clinical aspects of delirium that were described in the preceding article. Each case is followed by a discussion of the diagnosis, identification of the etiology, and subsequent treatment of an episode of delirium.