Addiction & Substance Use

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.

Although suicidal ideation occurs in roughly 5% to 14% of pregnancies,1 suicide attempts are relatively rare (0.04%) and are associated with substance abuse and poor pregnancy outcome.2 After a suicide attempt, the clinician must first consider the possibility of recurrence of self-destructive behavior by assessing the woman's motivation, her attitude toward the pregnancy, and the severity of her depressive symptoms.

In this issue, Drs Heinrich and Sponagle present a thorough overview of the challenges of detecting and treating delirium in the emergency care setting. They also address the high risks involved when the diagnosis is missed. The difficulties of identifying and appropriately managing delirium are not new. However, the importance of doing so is taking on a greater significance because of certain current and forecasted realities that will affect the nation's emergency departments (EDs).

Pathological gambling (PG) is characterized by persistent and recurrent maladaptive patterns of gambling behavior (eg, a preoccupation with gambling, the inability to control gambling behavior, lying to loved ones, illegal acts, and impaired social and occupational functioning).1 With past-year prevalence rates similar to those of schizophrenia and bipolar disorder,2 it is apparent that PG has become a significant public health issue. The aim of this article, therefore, is to introduce clinicians to the assessment and treatment of PG with the hope that early interventions will reduce the considerable personal and social costs associated with the disorder.

Psychiatry is the go-to specialty for determining whether a patient in need of inpatient hospitalization or has an alternative motivation?

Studies have shown that many pharmacologic agents are effective in the treatment of acute mania and bipolar relapse education.

Pharmacotherapy of Acute Schizophrenia

Risk Factors for Suicide in Patients With Schizophrenia

From Our Readers

DVD Aims to Educate Clinicians, Patients on Borderline Personality Disorder

Adult Growth, Internalizations, and Synaptogenesis

Nonconventional and Integrative Treatments of Alcohol and Substance Abuse (Part 1)

Psychological Therapies for Schizophrenia: Family and Cognitive Interventions

Sudden infant death syndrome (SIDS) is the leading cause of postneonatal death in the United States.1 This unfortunate disorder is characterized by the sudden, unexpected death of an of infant between ages 1 and 12 months whose cause of death remains a mystery in the aftermath of a thorough postmortem examination that includes an autopsy, an investigation of the death scene, and a careful review of the infant's medical history. New research, published in the November 2006 issue of The Journal of the American Medical Association,2 that made recent headlines confirmed earlier research by the same investigative team3,4 showing that serotonergic brain stem abnormalities may be the at the root of SIDS.