Bipolar Disorder

Since the discovery of dopamine as a neurotransmitter in the late 1950s, schizophrenia has been associated with changes in the dopaminergic system. However, the dopamine hypothesis of schizophrenia cannot explain all the symptoms associated with this disorder. Therefore, research has also focused on the role of other neurotransmitter systems, including glutamate, g-aminobutyric acid, serotonin, and acetylcholine (ACh) in schizophrenia.

The vesicular monoamine transporter (VMAT) is a membrane-embedded protein that transports monoamine neurotransmitter molecules into intraneuronal storage vesicles to allow subsequent release into the synapse.1,2 By accumulating both newly synthesized neurotransmitter molecules and freshly returned neurotransmitter molecules from the synapse, VMAT function plays a critical role in the signaling process between monoamine neurons. The VMAT exists in 2 distinct forms: VMAT1 and VMAT2.3

The modern era of psychopharmacology is only 60 years old, having begun with the discovery of the psychotherapeutic benefits of reserpine, lithium, monoamine oxidase inhibitors, and chlorpromazine in the late 1940s and early 1950s, which was followed a few years later by the synthesis and testing of the tricyclic antidepressants and benzodiazepines.

An international team of experts recently proposed expanding the diagnostic criteria for several subtypes of bipolar disorder, adding a pediatric bipolar disorder category and eliminating the schizoaffective disorder category.

Evidence-based medicine (EBM) is rapidly becoming the norm. It is taught in medical schools and is encouraged by both government agencies and insurance plan providers. Yet, there is little proof that this model can be adapted to fit psychiatry.

Concern about the rising number of preschool-age children receiving atypical antipsychotics, α-agonists, or other psychotherapeutic medications recently motivated pediatric mental health professionals to develop best-practice algorithms for psycho-pharmacological treatment of young children. It also prompted some states and mental health providers to initiate medication monitoring and consultation programs.

It is estimated that at least half of persons who begin antidepressant treatment will not respond to monotherapy.

The number of prescriptions for antipsychotic treatment of teenagers has increased sharply in office-based medical practice. Adolescents with psychotic symptoms frequently present for clinical evaluation, and early-onset schizophrenia spectrum disorders (onset of psychotic symptoms before the age of 18 years) represent an important consideration in the differential diagnosis in these youths

Congress substituted a 0.5% increase in Medicare fees for the first 6 months of 2008 for the 10% reduction that would otherwise have been enacted. That reduction in what is called the Medicare fee "update" was predetermined by a formula Congress itself put in place.

Reading crystal balls has always been difficult. Nevertheless, it may be a worthwhile exercise to stop and make some educated guesses about where the field of psychopharmacology will stand 10 years from now--knowing full well that insights and discoveries we cannot predict or anticipate now may pop up to dramatically change the course and direction of clinical psychopharmacology.

For many years, research on mood disorders has focused on neurotransmitters, particularly on the monoamines (serotonin, norepinephrine, and dopamine) and their action at the neuronal junction, or synapse. Although the monoamine theory helps explain the action of tricyclics, monoamine oxidase inhibitors, and SSRIs, it fails to account for many other things.

Panic disorder with or without agoraphobia is a chronic, debilitating psychiatric illness that affects about 4.7% of the general US population.

Both cognitive-behavioral and pharmacological treatments for panic disorder have been found to be effective over the short term. Not all patients, however, can tolerate or fully respond to these approaches, and the effectiveness of these interventions over the long term remains unclear.

When a suicidal patient in crisis calls the psychiatrist and hears the recorded message, "If you have a 'true' emergency, go to your nearest emergency room or call 911," the patient's risk of suicide may increase.

It is my great honor and pleasure as a psychiatric educator to teach many excellent medical students and residents. These young and not-so-young men and women are by and large diligent, highly professional, and caring.

A Public Health Approach to Intervening With Youth in Schools

Evidence for Use of Neurostimulating Techniques

Intensive psychosocial intervention was found to improve overall functioning in patients with bipolar depression, concluded researchers of the Systemic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) trial. Results were reported in the September 2007 issue of the American Journal of Psychiatry.

Although psychotropic medications have revolutionized the treatment of many psychiatric disorders, the benefits sometimes come at a price.

I was very pleased to read Robert Langs' letter ("Violence Against Mental Health Professionals," Psychiatric Times, July 2007), in the wake of Dr Fenton's death.

Paraphilias and paraphilia-related disorders (nonparaphilic sexual compulsivity or sexual addiction) are sexual disorders that predominantly afflict men.

Here is the conundrum: You have completed treatment with a fascinating and complex patient. Mr A has bipolar depression, Marfan syndrome, and hypothyroidism. You not only managed to navigate around the rocks of his medical problems, but you also managed to stabilize Mr A's bipolar disorder using a combination of lithium (Eskalith, Lithobid), thyroxine, and interpersonal therapy. You would now like to share your experience with colleagues, so you write up the case history; then suddenly, you are seized with misgivings.

A recent analysis that found a 40-fold increase in the diagnosis of bipolar disorder in youth has highlighted diagnostic dilemmas and prompted calls for more research studies.

Among clinicians and researchers in geriatric psychiatry, interest in late-life bipolar disorder is growing, fueled not only by the increasing size of this clinical population but also by the recent discovery that mood stabilizers such as lithium may influence the pathogenesis of Alzheimer disease.

Bipolar disorder (BD) in later life is a complex and confounding neuropsychiatric syndrome with diagnostic and therapeutic challenges.

Part 1 of this article, discussed a general approach to treating psychiatric emergencies in patients with bipolar and related disorders, as well as the assessment and management of agitation and impulsive aggression. Part 2 focuses on psychosis, suicidality, and specific treatments relevant to patients in emergency settings who are agitated or have bipolar disorder.

Parkinson disease (PD) is a progressive neurodegenerative disorder affecting 1% of people 65 years and older. The core symptoms include the motor manifestations of tremor, bradykinesia, and rigidity.

Book review

The articles in this Special Report, although far from comprehensive, address an intriguing sample of the many key topics in child and adolescent psychiatry today.

Early relapse is a limiting defect in electroconvulsive therapy (ECT). Although more than 80% of patients with a severe depressive illness who complete an acute course of ECT are relieved within three weeks, up to 60% relapse within six months, despite continuation treatments with antidepressant medications.1,2 In a large, government-supported, collaborative study led by the Columbia University Consortium (CUC), patients with unipolar major depression that had failed to respond to multiple trials of medications were treated with ECT to clinical remission and then randomly assigned to one of three continuation treatments--placebo, nortriptyline (Aventyl, Pamelor) alone, or the combination of nortriptyline and lithium (Eskalith, Lithobid). The patients were monitored for adequacy of blood levels.1 Within the six-month follow-up period, 84% of patients treated with placebo, 60% of patients treated with nortriptyline, and 39% of patients treated with the combination medications had relapsed.